Billing Plans: Allergy Drops (Q)

Recurring drops payments will push payment automatically.

Coupon code

Customer Information

Email Address *

Phone

Organization

Shipping Information

First Name *

Last Name *

Shipping Address 1 *

Shipping Address 2

Shipping Country *

Shipping City *

Shipping State *

Shipping ZIP Code *

Billing Information

All transactions are secure and encrypted.

Note: You will be billed by invoice for this subscription, the following billing information is optional. Your card will not be charged. Saving a credit card on file will make it easier to process future charges.

First Name on Account

Last Name on Account

Card Number

CVV

Expiration Month

Expiration Year

Billing Address

Use Shipping Address

Use a different Billing Address

Address 1

Address 2

Billing Country

Billing City

Billing State

Billing ZIP Code

Additional Information

Patient Date of Birth (FORMAT: 01/01/1999)

Patient Name

After your initial drops visit, would you like your drops mailed or would you like to pick them up?

Recurring Fee (every 3 months)	$150.00
Today's Total	$150.00
then $150.00 at first renewal on 07/20/2024
Note: You will receive invoices for all payments, you will not be charged automatically.