KRIPPS PHARMACY
Order Form

Order Online by Credit Card through PayPal


If you are a regular customer of Kripps, or ordering from Vancouver, please do not use the PayPal option. Proceed to order as you usually do by e-mail, sending your credit card information to us by fax
 
KRIPPS PHARMACY ORDER FORM-Printable Form

  BY FAX: (1) 604-685-9721

  BY PHONE: (1) 604-687-2564

  BY MAIL: 5413 West Boulevard Vancouver, B.C. Canada V6M 3W5

  BY E-MAIL: *Kripps Pharmacy

 
                                        SHIP TO: ( IF DIFFERENT) 
  NAME:____________________                        NAME:____________________ 
 
  STREET:__________________                          STREET:___________________ 

  CITY:_____________________                        CITY:___________________

  PROV/STATE:_____________                           PROV/STATE:______________

  POSTAL/ZIP CODE:_________                          POSTAL/ZIP CODE:_________

  TELEPHONE:______________                           TELEPHONE:_____________

  E-MAIL:___________________                        E-MAIL:_________________
ITEM #
PRODUCT DESCRIPTION
PRICE PER UNIT
UNITS ORDERED
TOTAL PRICE
         
         
         
         
         
         
         
         
         
         
Credit Card: MC or Visa circle one Sub Total: (1)___________
Card #:__________________ Shipping/Handling (2) __________
Expiry Date:____/_____ Sub Total:(3)_____________
Signature:______________ 5% GST Canada only:(4) _________
Ship by Mail or Air circle one Total: (5) __________
Money orders payable to Kripps Pharmacy