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intraMin by Drucker Labs

ORDER FORM FOR U.S. RESIDENTS
(not including delivery to HI or AK)

Prices include Shipping, Handling and Taxes

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

Last Name*
Last Name*

E-mail Address*
E-mail Address*

Street Address*
Street Address*

City*
City*

State/Prov*
State/Prov*

Zip/Postal Code*
Zip/Postal Code*

Country*
Country*

Home Phone*
Home Phone*

Name As It Appears on Credit Card*
Name As It Appears on Credit Card*

Credit Card Number*
Credit Card Number*

CCV # (last 3 digits on back of card)*
CCV # (last 3 digits on back of card)*

Expiration date*
Expiration date*

Credit Card Type*
Credit Card Type*

	Visa
	Mastercard

Amount of Purchase Being Authorized*
Amount of Purchase Being Authorized*

Confirm product selection:*
Confirm product selection:*

	Intramax - Peach Mango Flavour
	IntraKid - Raspberry Flavour
	IntraMin - Tropical Fruit Flavour
	IntraMin - Natural Unflavoured

IntraMin

IntraMin Monthly AutoShip

	1x 34oz Bottle shipment per month @ $67
	2x 34oz Bottle shipment per month @ $126
	1x case (12 x 34oz) bottles per month @ $540

IntraMin, Travel size

	6 x 2oz bottles - n/a
	12 x 2oz bottles - n/a

IntraMin cases

Custom order requests (including orders from HI & AK) can be submitted here and we will provide a quote within 24 hours.

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