Allergy Serum Reorder Form

Allergy Serum Reorder Form

To avoid missing doses, please remember to reorder your drops at least 10 business

days before you will run out. Your drops will be mailed directly to the address you list

below. The cost is $110, which includes shipping. You will be charged at the time you

order your drops. Please provide a credit card number, or mail a check with the order

form ($110.00 made payable to “AIM”).

Name: ______________________________ ________________ Date:

_______________

Address

(this is where the drops will be mailed)

: ______________________________ ____________

______________________________ ______________________________ ____________

Phone Number:

______________________________ _____________________________

Credit Card Number:

______________________________ _________________________

Expires: ________ v code

(3 digit code next to signature line on back of card)

: ____________

Signature:

______________________________ ______________________________ ____

Please mail this form to:

Asheville Integrative Medicine

832 Hendersonville Rd

Asheville, NC 28803

or Fax to: 828-281-3055

or email to: allergy@docbiddle.com

Allergy Serum Reorder Form

To avoid missing doses, please remember to reorder your drops at least 10 business

days before you will run out. Your drops will be mailed directly to the address you list

below. The cost is $110, which includes shipping. You will be charged at the time you

order your drops. Please provide a credit card number, or mail a check with the order

form ($110.00 made payable to “AIM”).

Name: ______________________________ ________________ Date:

_______________

Address

(this is where the drops will be mailed)

: ______________________________ ____________

______________________________ ______________________________ ____________

Phone Number:

______________________________ _____________________________

Credit Card Number:

______________________________ _________________________

Expires: ________ v code

(3 digit code next to signature line on back of card)

: ____________

Signature:

______________________________ ______________________________ ____

Please mail this form to:

Asheville Integrative Medicine

832 Hendersonville Rd

Asheville, NC 28803

or Fax to: 828-281-3055

or email to: allergy@docbiddle.com

Allergy Serum Reorder Form

To avoid missing doses, please remember to reorder your drops at least 10 business days before you will run out. Your drops will be mailed directly to the address you list below. The cost for inhalant drops is $110, which includes shipping. Food allergy drops are $165.00. You will be charged at the time you order your drops. Please provide a credit card number, or mail a check with the order form ($110.00, or 165.00 made payable to “AIM”).

Name: __________________________________________________ Date: ____________________________

Address (this is where the drops will be mailed): _________________________________________________

_________________________________________________________________________________________

Phone Number: __________________________________________

Credit Card Number:______________________________________

Expires: ________ Verification code:__________ (3 digit code next to signature line on back of card)

Signature: ________________________________________________________________________________

Please mail this form to:
Asheville Integrative Medicine
832 Hendersonville Rd
Asheville, NC 28803
or Fax to: 828-281-3055
or email to: allergy@docbiddle.com