|
Last Name:
|
* |
generic equivalent to
Mucinex®-D
Tablets
|
generic equivalent to
Mucinex®-D
Tablets
|
|
First Name:
|
*
|
|
Middle Initial:
|
|
|
Name on
credit card:
|
*
NO
GIFT CARDS OR PREPAID CARDS ALLOWED!
|
|
Cel
Phone:
|
*
Please
enter all zeros if you have no cell phone. (e.g. (000)000-0000)
|
|
Landline Phone:
|
*
Please
enter all zeros if you have no landline. (e.g. (000)000-0000)
|
|
|
|
Note: Both of the above
generics are manufactured by Watson.
|
|
Email Adress:
|
* |
Due to new Federal
Regulations on pseudoephedrine there is a limit of two (2) 18-Count packages per
household per transaction. Also, you may not purchase more than six
(6) 18-Count packages per 30 day period.
Your state may impose further
restrictions.
We will only ship to the
address that matches your photo ID. |
|
Home Address:
|
*
Provide
the address that appears on your Photo ID.
|
|
City:
|
*
|
|
State:
|
*
If your
U.S. state is not listed, we cannot ship there.
|
|
Zip Code:
|
*
|
NOTICE: Under 18 USC
§ 1001, anyone who makes a materially false, fictitious, or fraudulent
statement to the US Government is subject to criminal penalties.
Penalties may include a fine of up to $250,000 and/or imprisonment for up
to 5 years. |
|
Country:
|
|
|
|
|
|
|
Select your card:
|
|
 |
|
Card number:
|
*
|  |
|
Card expiration:
|
/
* |
|
CV V 2
|
*
(Security Code) |
|
QUANTITY:
|
Due
to limited availability, we're currently limiting this item to 1 package
every 7 days per household.
|
|
|
I'm Sending my Photo ID by:
|
|
Not sure?
Please send your ID again. |
|
Special Instructions
or comments:
|
|
|
|
AUTOSHIP?
|
, EVERY DAYS |
With AutoShip,
we'll
automatically bill your card on file and ship your order to
you until either your credit card or photo ID expires or you cancel.
To cancel or change frequency of shipments please send email to Services@RxPalace.com |
