Order

Date

Your Name *

Enter your full name

DOB *

Shipping Address *

Shipping Address

City

State/Province

Zip/Postal

Do you have different billing address? *

Yes

No

Billing Address *

Billing Address

City

State/Province

Zip/Postal

Contact Phone *

Email *

Products *

The Magic Pill ($39.99)

Hand Sanitizer 2oz Bottle (Travel size $5.00)

Hand Sanitizer 4oz Bottle ($10.00)

Hand Sanitizer 8oz Bottle ($15.00)

Credit Card Authorization Form

Credit Card Type *

MasterCard

VISA

Discover

AMEX

Credit Card Number *

Expiration Date *

Security Code *

This is the number from the back of your card.

Name on the card. *

Authorized Signature *

Clear

Draw your E-Signature.

By signing this form, you give us permission to keep the above credit card on file and charge it for future orders. The card on file can be changed prior to your next transaction.

You are authorizing Gulf Coast HRT to charge and sign your card for future transactions using SQUARE.

*Gulf Coast HRT reserves the right to have NO RETURN and NO REFUND policy.

Products Order Form

Credit Card Authorization Form