Generic Latisse Order Form

First Name*

Last Name*

Date of Birth*

Alberta Health Card Number*

Cell Phone Number*

Email Address*

Image of your drug coverage card(s) (If applicable)

Please attach the picture of your drug coverage card(s) for billing.

Delivery Date*

Preferred Delivery Time*

Street Address*

Address Line 2*

City*

Province*

Postal Code*

Delivery Notes*

e.g. Leave at Joan at reception, place in mail box, call me when they are at the entrance.

Terms of Service*

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