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 SpagoMed Laboratories
Order Form
2123-21320 Westminster Hwy.
Richmond,
B.C., V6V 1B6
Ph: Local 604.821.1285 Fax 604.821.1287
Ph: 1 800 681 2292 Fax: 1 888 663 5577 Date: _____________
Ship
To:
Billing Info:
_______________________________________
Mastercard:
_______________________
_______________________________________ VISA
Card:
Cardholder name:
_______________________________________ Card
#: _____________________________
_______________________________________ Exp.:
____/____ Name on Card:________
I
would like to order:
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Signature : _____________________________________
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