Derma-Cap Order Form

To Order by Mail simply fill in the appropriate blanks in the form below, then print the form with the print funtion of your web browser. Fields marked with an asterisk * are required.
MAIL TO: Nutrimed Labs, Inc., 7200 N. State Highway 161, Suite 110, Irving, TX, 75039

To Order by Fax follow the instructions below

For prescription strength DermaCap^TM:

Print this prescription form using the print function of your web browser

Have your medical doctor fill in the product selection and signature

Fill out the order form (below) to provide us with shipping and payment information

Fax the prescription, order form and a copy of your medical insurance card to 800-687-1836

For non-prescription strength DermaCap^TM:

Fill out the order form (below) to provide us with shipping and payment information

Fax order form to 800-687-1836

DERMACAP^TM ORDER FORM

Name: *

Address 1: *

Address 2:

City: *

State: *

Zip/Postal Code: *

E-Mail: *

Phone: *

Fax:

Comment:

Quantity	Product Name and Size	Unit Price	Total Price
	Prescription-strength Topical Spray Bottle, 4 oz.	$69.95
	Prescription-strength Cream Jar, 2 oz.	$59.95
	Prescription-strength Shampoo, 4 oz.	$69.95
	Non-Prescription Topical Spray Bottle, 4 oz.	$30.00
	Non-Prescription Cream Jar, 2 oz.	$25.00
	Non-Prescription Shampoo, 4 oz.	$30.00
	Total number of products ordered x $6.00 each for shipping
TOTAL:

Payment: *

Credit Card Number:

Exp. Date

CVV number required

What is a CVV number?

MAIL TO: Nutrimed Labs, Inc., 7200 N. State Highway 161, Suite 110, Irving, TX, 75039