THIS IS FOR WASHINGTON STATE DENTISTS
ONLY
Randy's Compounding Pharmacy & Nutrition Center
1908 E. 4th Ave.
Olympia, WA 98506
1-800-455-6888
(360) 491-0607
FAX: 360-491-0629
e-mail: info@soundcompounding.com
Website: randyscompoundingpharmacy.com
To order Psi-clone, please indicate the type and the number of 30 ml
bottles you would like and submit your
check, or credit card number along withthis order form. The prices
include shipping costs.
PLEASE SUBMIT PRESCRIPTION FORM FOR SUCK-CESS-- go to Handouts,
Number 11B.
Doctor: _________________________________ Date: ________________
Address: _______________________________________________________
_______________________________________________________
Phone: ________________________ FAX: __________________________
Qty. Doctor's Price Subtotal
( ) Psi-clone 1% Liquid $49.75 ________
( ) Psi-clone gel $49.75 ________
( ) Suck-cess tube $20.00 ________
Total
________
SIG:
For office use only
Not to be dispensed or resold
_______________________________________________________
Doctor's Signature
Method of payment:
Check enclosed ( ) Credit Card: VISA ( ) Mastercard ( ) Discovercard ( )
Number of card: _____________________________________ Exp. date ________
Signature: ___________________________________________________________