Mail Order Form

Order Erexis^™by Mail

Please print this page, fill out your order and send with payment.

I would like to order the following:

My order total is $ _____________

I'm paying by credit card

Name on Card: ____________________________

Card Number: _____________________________

Expiration Date: ___________________________

Card type:

I'm paying by check

I'm paying by money order

Ship To Information:

Name: ______________________________________

Address: ____________________________________

City, State, Zip: ______________________________

All orders are packaged discreetly and all information regarding orders are kept strictly confidential and will never be sold to other companies.

Print and Send order to:

Biogenica
12905 SW 132 Street, Suite 4
Miami, FL 33186

Postal Money Orders and credit card payments are processed within 24 hours of receipt. Personal checks and other money orders require 10 days to clear.

Order Erexis™ by Mail

I would like to order the following:

My order total is $ _____________

Ship To Information:

All orders are packaged discreetly and all information regarding orders are kept strictly confidential and will never be sold to other companies.

Print and Send order to:

Postal Money Orders and credit card payments are processed within 24 hours of receipt. Personal checks and other money orders require 10 days to clear.

Order Erexis^™by Mail