Generic Latisse Order Form

First Name*
Last Name*
Date of Birth*

DD
MM
YYYY
Alberta Health Card Number*
Cell Phone Number*
Email*
Drug coverage if applicable
Please attached a picture of your drug coverage for billing.
Date you would like delivery
Date Format: MM slash DD slash YYYY
Preferred Delivery Time
Courier verified two-hour delivery window will be sent to you on the day of delivery.
Delivery Address*
Street Address Address Line 2 City Province Postal Code
Delivery Notes
e.g. leave with Joan at reception, place in mail box, call when at entrance,
How did you hear about us?
Terms of Service*
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