Printable Order Form

To order from PharmaMX.com, just print and complete this form and mail it to:
SERVICOM EMPRESARIAL MEXICO, S.A. DE C.V.
NADADORES No. 30 COL. COUNTRY CLUB CH.
C.P. 04210, MÉXICO, D.F.
Fax: +52 55 5689-4254

SKU Medicine Name Dosage (gr, mg, mcg) Price Quantity Total per Item
           
           
           
           
           
           
Subtotal: USD$
Shipping and Handling: USD$ 10.00

Total cost:
Your items plus shipping costs.

 USD$
PLEASE NOTE: Because all orders are shipped via registered mail from Mexico, we cannot process urgent orders.
Please allow 10 to 14 business days since your order request is received to receive your order.
 All prices shown on our product list are in American Dollars.
Please make your Check or Money Order payable to
SERVICOM EMPRESARIAL MEXICO, S.A. DE C.V.
 How did you know about PharmaMX.com?
 (From Google.com, classified ads, ,magazine, newspaper, friend?
  If by search engine, which one?)


__________________________________________________
Billing Address
Your Name:
Street: City:
State: Postal Code:
Country: Email Address:
Daytime Area Code and Phone:
Shipping Address
Your Name:
Street: City:
State: Postal Code:
Country: Email Address:
Daytime Area Code and Phone:
FOR CREDIT/DEBIT CARD PAYMENT PLEASE FILL THE FOLLOWING INFORMATION
Cardholder name:  
Card: Credit Card                  Debit Card
Type: MASTER CARD                  VISA                      VISA ELECTRON
Credit Card Number: _________________________________________________                 _______________________
Please, verify your credit card number before you send it to us.                      Security ID from your card
Expiration Date: Month______ Year ______

REFILL REQUEST (Optional)
How often?:

    Monthly  Each three months  Each six months

How many times?:
(charging and delivering)		 Never expires this refill Refill until ____/_____/______/  (MM/DD/YYYY) _____ Times

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