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LABS ORDER FORM Eye Complex Physician's Reserve Please print and complete this form carefully. You must include this form along with your payment to place an order with Civant Pharma. ALL PAYMENTS MUST BE MADE OUT TO "CIVANT LABS". WE WILL NOT ACCEPT ANY PAYMENT MADE OUT TO EYE COMPLEX. If you reside outside of the United States, Canada or the United Kingdom, we suggest you email us at info@eyecomplex.com prior to ordering to confirm if your address is an acceptable delivery location. We are not responsible for payments lost in transit. To order by mail, please fill out this form and send it along with your payment to the address listed at the bottom of this form. You can pay by money order or cashiers check made out to "Civant Labs". We do not accept personal checks. Currency must be in the form of United States Dollars (USD). For large orders, please email us in advance to verify availability. Full Name: Phone Number: Email Address: Shipping Address:
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