Dispensary products are intended for Cottage Clinic patients only.

* = required field

*First Name	*Last Name
*Address:     *City:    *Zip:
*Date of Birth (mm/dd/yyyy
*Best # to reach you for payment	Home:
	Work:
	Mobile:
It's ok to leave a message	yes    no
*Supplement Name:	*Company Name:
*Strength/Mg     *liquid, pill, or powder?   *How Many Bottles
Supplement Name:	Company Name:
Strength/Mg     liquid, pill, or powder?   How Many Bottles
Supplement Name:	Company Name:
Strength/Mg     liquid, pill, or powder?   How Many Bottles
Supplement Name:	Company Name:
Strength/Mg     liquid, pill, or powder?   How Many Bottles
Mail my order   I will pick it up	Please call the office with credit card information 206.361.2602
Comments:
*Supplements will be mailed within 2 business days after order is confirmed and payment is received. There will be a flat fee of $5.00 for shipping unless informed otherwise. Unpaid supplement orders will be held at the clinic for 5 business days. If payment is not received within 5 business days your order will be cancelled and a 15% restocking fee will be charged.
I agree I am a patient of Cottage Clinic