| Last
Name: |
* |
Alavert-D® 12 Hour
(24 Tablets) or
Claritin-D® 12 Hour
Tablets (20 Tablets)
 
Both
products above contain:
5mg
Loratadine and 120mg Pseudoephedrine Sulfate |
| First Name: |
* |
| Middle Initial: |
|
| Name
on
credit card: |
*
No
Gift Cards or Pre-paid Cards
|
| Cel
Phone: |
*
Please
enter all zeros if you have no cell phone. (e.g. (000)000-0000)
|
| Other Phone: |
|
|
Email Adress:
|
* |
Due to Federal
Regulations on pseudoephedrine there is a limit of one (1) package per
household per transaction. Also, you may not purchase more than two
(2) packages per 30 day period.
* We will only ship to the
address shown on your photo ID unless you provide additional
documentation. |
|
Home Address:
|
*
Provide
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: |
|
|
We do not ship this product
outside the United States |
| Select your card: |
|
 |
| Card number: |
*
|  |
| Card expiration: |
/
* |
| CV V2 |
*
(Security Code) |
| |
|
| I'm Sending my Photo ID by: |
|
Not sure?
Please send your ID again. |
| QUANTITY: |
|
Maximum is 1 package per purchase for
this item. |
| Special Instructions
or comments: |
|
|
|
|
*
| Quantity: |
|
| Frequency: |
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 |
|
Shipping Method:
|
Items usually ship 1-3 days after
order placed.
Due
to the special order requirements of this product, it will NOT appear in
your shopping cart. If you'd like to purchase other items you can
do so and we'll combine your orders when we ship to you.
|
We will only ship to the
address that is shown on your Photo ID unless you provide additional
documentation (e.g. copy of a paper Utility Bill that clearly shows your name and
address).
When we process your
credit card we use AVS technology to verify your address.
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