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ORDER FORM - CANADA

Retail Order Form - Prices in Canadian Dollars
This is a secure order site
Send Your SINUS RINSE™ Order By Any Of The Following Methods:
Mail Please print the form, fill out your order, then mail to:
NeilMed Pharmaceuticals, Inc.
Attn: Retail Sales Dept.
P.O. Box #3553
Markham, Ontario  L3R 6G8
CANADA		 By Tel:  Please call (905) 480-0202 or (877) 477-8633  to place your order.
By Fax:   Please print the form, fill out your order, then fax to (905) 480-0201
By Web:   Please fill out the on-line form below , then press the SUBMIT button.(Via Secure Server)
(Physicians, Chemists, Pharmacies, Hospitals and Retailers; please call us for wholesale prices.)
Item (click for details)
Price
Quantity
Total
sinusrinse kit
C$16.50
C$18.00
C$5.00
C$16.50
C$18.00
C$5.00
C$6.99
C$8.99
C$6.99
C$8.49
C$18.00
C$5.00
C$16.50
C$18.99
C$16.50

C$5.00

SUB TOTAL(C$)

     GST Sales Tax (5.0%)
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Ontario Residents Add PST (8.0%)