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Rhinostat Systems, LLC Mail In Order Form |
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| Ship To Information: | |||||
| Name | |||||
| Address | |||||
| City |
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State |
Zip |
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| Where can we contact you if we have any questions about your order? | |||||
| Phone | |||||
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IMPORTANT - Please Check One Active Compound: What is the name of the active ingredient listed on the bottle of your current decongestant spray? |
Oxymetazoline | |
| Phenylepherine | ||
| Xylometazoline | ||
Your Order: Normally, a single person needs only one kit. Please enter the quantity desired and then multiply by the cost per kit. |
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QUANTITY |
DESCRIPTION | SHIPPING | TOTAL | EXTENDED |
| RHINOSTAT KIT $39.00 | PRIORITY MAIL $5.95 (Suggested Method) | $44.95 | ||
| RHINOSTAT KIT $39.00 | UPS 2ND DAY AIR $15.00 | $54.00 | ||
| RHINOSTAT KIT $39.00 | UPS NEXT DAY AIR $35.00 | $74.00 | ||
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GRAND TOTAL |
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| Mail Completed Form To: | Rhinostat Systems, LLC 82 Mill Plain Road Danbury, CT 06811 |
| Your order will ship within one business day of our receipt of this form. Please do not send cash. Rhinostat accepts personal checks as well as money orders | |