Order Form

 

FAX:   805-484-1069

MAIL: Jamila Diabetes and Endocrine Medical Center, Inc.

1429 E.Thousand Oaks Blvd. Suite 105, Thousand Oaks, CA 91362. 

 

BILLING INFORMATION: 

 

NAME:___________________________________________________

 

ADDRESS: ____________________________________________

 

CITY: ___________________ STATE________ ZIP: __________

 

CONTACT TEL:_________________ E MAIL:_________________

 

SHIPPING INFORMATION: Only if Different from Billing Info.

 

NAME: _______________________________________________

 

ADDRESS: ____________________________________________

 

CITY: __________________STATE _______ ZIP:__________

 

METHOD OF PAYMENT: 

 

MASTERCARD: _____             VISA: _____ 

 

CREDIT CARD NO: _____________________________________

 

EXPIRATION DATE:_____________________________________

 

CARDHOLDER'S SIGNATURE:____________________________

 

ITEM QUANTITY Unit PRICE Total Price
       
       
       
       
    Shipping& Handling.
Use the calculator below.
 
    7.25% sales tax for California residents only.  
    ORDER TOTAL  
                                       

 

   SHIPPING COST CALCULATOR

Total Price Shipping cost Total Price Shipping cost Total Price Shipping cost

$1.00 to 50.00

$5.00

$51.00 to 100.00

$7.00

$101 and up

$ 10.00

Please note that we only accept US Dollars.

We ship within U.S.A. only. No international orders please. We apologize for the inconvenience. 

For questions, please call 1-888-495-2002.