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Printable Order Form
INTERNATIONAL CUSTOMERS:  Please follow the procedure below to place your order.  

  1. Determine the total weight of your order by clicking on:  Product Weight Table 

  2. Calculate shipping costs for your country and for your order by clicking on:  Shipping Costs

  3. Fill in the form below (including the shipping costs for your order) and fax to 1-508-495-4035  or mail with your international money order to:  KALA Health, Inc., PO Box 936, Falmouth, MA 02541, USA .   Please don't forget to sign the form!
Name:
Address:
City:   State:  Zip: 
Country:
Phone:
Email:
Please List Product Name, Quantity and Item Number:
Join Auto-Shipment Program? Please give frequency
Total Shipping Costs (see instructions on top of this page):
Method of Shipment
Credit Card:
VISAVISA
MasterCardMasterCard		 DiscoverDiscover 
AMEXAmerican Express
Credit Card #:
Expiration Date and Security Code     Security Code:
Your Signature:
(Please sign after printing)  		 _____________________________________

TO PRINT: Click on this icon:                   FAX Number: 1-508-495-4035