EHAC-STL Where People Come to Get Well

For accuracy we recommend that you order on-line with this secure form or fax us your order as opposed to ordering over the phone. If ordering by phone, please provide same information as listed below. For allergy extracts preparation ordered over the internet please allow 1 week; otherwise allow 2 weeks. Supplements are usually ready for pick-up or mailing in two working days.

Thank you
Staff at EHACstl.

Telephone: (314) 921 5600 Fax: (314) 9218273

* Indicates Required Fields

* Patient's First Name
* Patient's Last Name
* Patient's Address
Apartment/Suite
* City
* State
* Zip Code
Your Name if different than patient's
* Phone Number
* E-Mail Address

* Name on Credit Card
* Credit Card Type
* Credit Card Number
* Expiration (mm/yy)
* Card Validation Code		MasterCard, Visa & Discover Example American Express Example
If you currently have insurance and know the co-pay please enter the estimated amount here as $ amount or % amount. If you are not sure of your co-pay we will charge the estimated co-pay for any allergy extracts ordered.
Estimated Copay	$ or %

Allergy Extracts
To prevent errors in the ordering process please specify the exact name of the extract as it appears on the bottle. If number of vials is not specified only 1 will be prepared.

* Delivery Method

No extracts selected

Mail me the extracts

I will pick up the extracts

Name of Extract

# of Vials

Supplements
To prevent errors in the ordering process please specify the exact name of the supplement as it appears on the bottle.

* Delivery Method

No supplements selected

Mail me the supplements

I will pick up the supplements

Name of Supplement

# of Bottles


Type the characters shown in image for verification.*
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