Order Products Order Form Date Your Name * Enter your full name DOB * Shipping Address * Shipping Address Shipping Address Shipping Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Do you have different billing address? * Yes No Billing Address * Billing Address Billing Address Billing Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal 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 Keystone Alternative Medicine to charge and sign your card for future transactions using SQUARE. *Keystone Alternative Medicine reserves the right to have NO RETURN and NO REFUND policy. Submit