Food-Medication Interactions Secure Order Form 

Please use the Tab Key to move from field to field thru the order form
 USE the Enter Key ONLY when you
 are ready to SUBMIT your ORDER
 


    * Required information

Part 1 - Customer Information:                        

*Customer Name: 
 Institution: 
*Shipping Address1: 
   *City: *State:  *Zip: 
*Credit Card Billing Address: 
   *City: *State:  *Zip:
  Country: 
*Telephone:  Fax: 
 E-mail: 

Part 2 - Product Information:
ITEM QTY PRICE EA. TOTAL
1. FMI Handbook 17th Edition

 X

=     $
2. FMI Software for PC

X

=     $

3. FMI Software for PDA
Important:
Check which OS:
Android
Blackberry
iPhone

 Regular Price  $104.95 
 X $89.95
  LIMITED TIME Price  

=     $
4. Special: 
FMI Software for PDA +  FMI Handbook 
(Check Box Above for 
Android, Blackberry or iPhone) 

 X $110.95

=     $
5. SUBTOTAL

Add Lines 1 through 4:

$
6. Shipping & Handling, Books.

Enter total number of books here:
7. Shipping & Handling, PC Software:
8. Shipping & Handling, PDA Software:
9. Tax

Pennsylvania Residents 
add 6% Sales Tax:

$
10. IMPORTANT: In Canada add $5 per book; all other countries outside the U.S., please call or email for correct shipping charges. $
11. GRAND TOTAL

Add Lines 5 through 10:

$

Part 3 - Payment Options (please check one box):
 Pay by Credit Card

Card: Card Number: 
Expiration Date: 
Name as it appears on Card: 

 Pay by Check


Part 4 - Ordering Options:

CURRENTLY THE ONLINE ORDERING SYSTEM IS NOT WORKING. PLEASE FAX YOUR ORDER (610-827-7669) OR TO ORDER BY PHONE (800-746-2324).

To submit via the Web (credit card only), click here once: 

To order by Fax (credit card only), print this form, and fax to (610) 827-7669.

To order by regular mail, print this form, and send with payment 
(credit card, check or money order
drawn on a US bank in US funds) to:

FOOD MEDICATION INTERACTIONS
PO Box 204, Birchrunville, PA 19421 USA

For questions or comments, contact us:
E-mail: foodmedint@aol.com 
Telephone
: (800) 746-2324 or (610) 827-7800
Fax: (610) 827-7669

Thank You For Your Order!


Copyright 1997-2012 Food-Medication Interactions.
Last updated: 05-Jul-2013