Order Form

Name of Pharmacy Owner/Manager *

First Name

Last Name

Consent to Payment *

I agree to pay a fee of $3000 (+GST) for a customized Level A compounding compliance kit for implementation at a single pharmacy upon receipt of the invoice at the email provided above.

Consent to Copyright *

I understand all items delivered as part of the compounding kit are subject to Copyright and are for individual use at the pharmacy listed above.