MEDICAL HISTORY AND SCREENING FORM General InformationHiddenLocation HiddenViking Location VIKING ALTERNATIVE MEDICINE - CORPORATE Viking Chesterfield -132 Chesterfield Town Centre, Chesterfield MO 63005 TriMax Health and Fitness HiddenReferral ID ParticipantFull Name ( Legal name)* First Middle Last HiddenPreferred Name (if different from above) HiddenDate of Birth* MM slash DD slash YYYY Email* HiddenPhone*HiddenAlternate NumberHiddenAddress* Street Address Address Line 2 City ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHPuerto RicoOKORPAPRRISCSDTNTXUTVIVTVAWAWVAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanWIWY State ZIP Code How did you hear about Viking Alternative Medicine?HiddenHow did you hear about PureHRT?Ethnicity American Indian Alaskan Native Black or African American Hispanic or Latino Asian White Native Hawaiian or Pacific Islander Patient Declined Other Other Marital Status Single Married Divorced Widowed Sex* Male Female PurposeWhat is/are your purpose(s) for participating in the HRT program? To determine my current level of health and to receive a possible recommendation. Other Other PurposeCurrent Medical HistoryMedical history checkboxesCheck those questions to which you answer yes. Leave all others blank. Has a doctor ever said your blood pressure was too high? Do you ever have pain in your chest or heart? Are you often bothered by a thumping of the heart? Does your heart often race? Do you ever notice extra heartbeats or skipped beats? Are your ankles often abnormally swollen? Do cold hands or feet trouble you even in hot weather? Has a doctor ever said that you have had heart trouble, an abnormal echocardiogram or EKG, heart attack or coronary? Do you suffer from frequent cramps in your legs? Do you often have difficulty breathing? Do you get out of breath long before anyone else? Do you sometimes get out of breath when sitting or sleeping? Has a doctor ever told you that your cholesterol level was high? Has a doctor ever told you that you have an abdominal aortic aneurism? Has a doctor ever told you that you have a critical aortic stenosis? None of the above Comments:Do you now have or have you recently experienced? chronic, recurrent or morning cough? episodes of coughing up blood? increased anxiety or depression? Problems with recurrent fatigue, trouble sleeping or increased irritability? migraine or recurrent headaches? swollen or painful knees or ankles? swollen, stiff or painful joints? pain in your legs after walking short distances? foot problems? back problems? stomach or intestinal problems such as recurrent heartburn, ulcers, constipation or diarrhea? significant vision or hearing problems? recent change in a wart or mole? glaucoma or increased pressure in the eyes? exposure to long noises for long periods? an infection such as pneumonia followed by fever? significant unexplained weight loss? a fever which can cause dehydration and rapid heartbeat? a deep vein thrombosis (blood clot)? a hernia that is causing symptoms? foot or ankle sores that won’t heal? persistent pain or problems walking after you have fallen? eye symptoms such as bleeding the retina or detached retina? cataract or lens transplant? laser treatment or another eye surgery? None Comments:Women only answer the following:Do you have? menstrual period problems? significant childbirth related problems? urine loss when you cough, sneeze or laugh? Date of last pelvic exam and/or PAP smear: MM slash DD slash YYYY Are you on any type of hormone replacement therapy? Yes No Comments:Men and Women, both, answer the following:List any prescription medications you are now taking:List any self-prescribed medications, dietary supplements or vitamins you are now taking:Date of last complete physical examination: MM slash DD slash YYYY Last Physical exam results Normal Abnormal Never Can't Remember Date of last chest x-ray: MM slash DD slash YYYY Chest x-ray results Normal Abnormal Never Can't Remember Date of last echocardiogram (EKG or ECG): MM slash DD slash YYYY EKG Results Normal Abnormal Never Can't Remember Date of last dental exam: MM slash DD slash YYYY Dental Results Normal Abnormal Never Can't Remember List any medical or diagnostic testing you have had in the last two years:List hospitalizations including dates of and reasons for hospitalizations:List all allergies to drugs:Past Medical HistoryCheck those questions to which you answer yes. Leave all others blank. Heart attack Heart murmur Varicose veins Diabetes or abnormal blood sugar tests Dizziness or fainting spells Stroke Scarlet fever Infectious mononucleosis Thyroid problems Pneumonia Asthma Other lung disease Bronchitis Jaundice or gallbladder problems Rheumatic fever Diseases of the arteries Arthritis of the legs or arms Phlebitis (inflammation of a vein) Epilepsy or seizures Diphtheria Nervous or emotional problems Anemia Abnormal chest x-ray Injuries to back, legs, arms or joints Broken bones none Comments:Note: include heart attack date.We will need a copy of your current bloodwork and your drivers license prior to ordering medication. If you have them handy, please submit them here, otherwise please continue with the form.Please upload a copy of your Driver License Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, Max. file size: 128 MB. Please upload a copy of your most recent Laboratory Results Drop files here or Select files Accepted file types: jpg, jpeg, png, pdf, Max. file size: 128 MB. Patient Authorization for Delivery of MedicationsConsent and Authorizations I consent and authorize the the following:I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used. I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. No Guarantee of Services Viking Alternative Medicine does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign up process and physician’s examination. At the physician’s discretion you will be provided medications and/or services during your program at Viking Alternative Medicine. No Refund Policy *Viking Alternative Medicine reserves the right to have NO RETURN and NO REFUND policy.HiddenConsent and Authorizations I consent and authorize the the following:I hereby authorize the clinic staff on duty to act on my behalf to accept medication delivery from the clinics dispensing physician and deliver my medications and refills to me as prescribed by my provider. I understand that the provider is not responsible for lost or damaged good and all issues regarding mail delivery shall be handled through the mailing company used. I understand that I may be required to come to the office to accept delivery of such medications from the staff on duty on a weekly basis (or as often as ordered by the physician). This authorization will remain active for the course of my treatment at this clinic or until I revoke it in writing. No Guarantee of Services Viking Alternative Medicine does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign up process and physician’s examination. At the physician’s discretion you will be provided medications and/or services during your program at PureHRT. No Refund Policy *PureHRT reserves the right to have NO RETURN and NO REFUND policy.HiddenName First Middle Last Informed Consent for Hormone Replacement TherapyHiddenTerms of Service and Privacy PolicyWHO WE ARE Viking Alternative Medicine, LLC (Viking) Our website address is: https://vikingalternative.com. PRIVACY POLICY This privacy policy (“Policy”) describes how we collect, protect and use the personally identifiable information (“Personal Information”) you (“User”, “you” or “your”) provided on the https://vikingalternative.com website and any of its products or services (collectively, “Website” or “Services”) owned and operated by VikingAlternative.com, “us”, “we” or “our”). It also describes the choices available to you regarding our use of your personal information and how you can access and update this information. This Policy does not apply to the practices of companies that we do not own or control, or to individuals that we do not employ or manage. COLLECTION OF PERSONAL INFORMATION We receive and store any information you knowingly provide to us when you create an account, publish content, make a purchase, or fill out any online forms on the Website. When required this information may include your email address, name, address, or other Personal Information. You can choose not to provide us with certain information, but then you may not be able to take advantage of some of the Website’s features. COLLECTION OF NON-PERSONAL INFORMATION When you visit the Website our servers automatically record information that your browser sends. This data may include information such as your computer’s IP address, browser type and version, operating system type and version, language preferences or the webpage you were visiting before you came to our Website, pages of our Website that you visit, the time spent on those pages, the information you search for on our Website, access times and dates, and other statistics. MANAGING PERSONAL INFORMATION You are able to access, add to, update, and delete certain Personal Information about yourself. The information you can view, update, and delete may change as the Website or Services change. When you update information, however, we may maintain a copy of the unrevised information in our records. We will retain your information for as long as your account is active or as needed to provide you Services. Some information may remain in our private records after your deletion of such information from your account. We will retain and use your information as necessary to comply with our legal obligations, resolve disputes, and enforce our agreements. We may use any aggregated data derived from or incorporating your Personal Information after you update or delete it, but not in a manner that would identify you personally. USE OF COLLECTED INFORMATION Any of the information we collect from you may be used to improve our website; improve customer service and respond to queries and emails of our customers; process transactions; send notification emails such as password reminders, updates, etc; run and operate our Website and Services. Non-personal information collected is used only to identify potential cases of abuse and establish statistical information regarding Website traffic and usage. This statistical information is not otherwise aggregated in such a way that would identify any particular user of the system. BILLING AND PAYMENTS We use third-party payment processors to assist us in processing your payment information securely. Such third-party processors’ use of your Personal Information is governed by their respective privacy policies which may or may not contain privacy protections as protective as this Privacy Policy. We suggest that you review their respective privacy policies. CHILDREN We do not knowingly collect any personal information from children under the age of 13. If you are under the age of 13, please do not submit any personal information through our Website or Service. We encourage parents and legal guardians to monitor their children’s Internet usage and to help enforce this Policy by instructing their children never to provide personal information through our Website or Service without their permission. If you have reason to believe that a child under the age of 13 has provided personal information to us through our Website or Service, please contact us. NEWSLETTERS We offer electronic newsletters to which you may voluntarily subscribe at any time. You may choose to stop receiving our newsletter or marketing emails by following the unsubscribe instructions included in these emails or by contacting us. However, you will continue to receive essential transactional emails. COOKIES The Website uses “cookies” to help personalize your online experience. A cookie is a text file that is placed on your hard disk by a web page server. Cookies cannot be used to run programs or deliver viruses to your computer. Cookies are uniquely assigned to you, and can only be read by a web server in the domain that issued the cookie to you. We may use cookies to collect, store, and track information for statistical purposes to operate our Website and Services. You have the ability to accept or decline cookies. Most web browsers automatically accept cookies, but you can usually modify your browser setting to decline cookies if you prefer. If you choose to decline cookies, you may not be able to fully experience the features of the Website and Services. There are three types of cookies used on VikingAlternative.com: Our content management system uses cookies to track information required to operate the site, which includes allowing members to log in, comment, and interact with their membership. This site uses Google Analytics to track site usage to help improve services for all. The Google Analytics tracking cookie has zero remarketing (not used to track once you leave the site) and utilizes the IP anonymization feature to protect individual privacy. This site also uses a tracking cookie (getBeamer) to deliver the latest ‘unseen’ news through that floating icon on the bottom right of the screen. This is a session cookie and does not track you once you leave FeelLikeaViking.com If you would like to disable FeelLikeaViking.com from using any cookies with your browser, be aware that disabling cookies will render your browser unable to log in to the site and therefore unable to interact with your membership. If you still desire to disable cookies, VikingAlterntive.com suggests you read more about managing your own cookies at www.allaboutcookies.org/manage-cookies AFFILIATES We may disclose information about you to our affiliates for the purpose of being able to offer you related or additional products and services. Any information relating to you that we provide to our affiliates will be treated by those affiliates in accordance with the terms of this Privacy Policy. LINKS TO OTHER WEBSITES Our Website contains links to other websites that are not owned or controlled by us. Please be aware that we are not responsible for the privacy practices of such other websites or third parties. We encourage you to be aware when you leave our Website and to read the privacy statements of each and every website that may collect personal information. INFORMATION SECURITY We secure information you provide on computer servers in a controlled, secure environment, protected from unauthorized access, use, or disclosure. We maintain reasonable administrative, technical, and physical safeguards in an effort to protect against unauthorized access, use, modification, and disclosure of personal information in its control and custody. However, no data transmission over the Internet or wireless network can be guaranteed. Therefore, while we strive to protect your personal information, you acknowledge that (i) there are security and privacy limitations of the Internet which are beyond our control; (ii) the security, integrity, and privacy of any and all information and data exchanged between you and our Website cannot be guaranteed; and (iii) any such information and data may be viewed or tampered with in transit by a third party, despite best efforts. DATA BREACH In the event we become aware that the security of the Website has been compromised or the user’s Personal Information has been disclosed to unrelated third parties as a result of external activity, including, but not limited to, security attacks or fraud, we reserve the right to take reasonably appropriate measures, including, but not limited to, investigation and reporting, as well as notification to and cooperation with law enforcement authorities. In the event of a data breach, we will make reasonable efforts to notify affected individuals if we believe that there is a reasonable risk of harm to the user as a result of the breach or if notice is otherwise required by law. When we do we will post a notice on the Website, and send you an email. CHANGES AND AMMENDMENTS We reserve the right to modify this privacy policy relating to the Website or Services at any time, effective upon posting of an updated version of this privacy policy on the Website. When we do we will revise the updated date at the bottom of this page. Continued use of the Website after any such changes shall constitute your consent to such changes. ACCEPTANCE OF THIS POLICY You acknowledge that you have read this Policy and agree to all its terms and conditions. By using the Website or its Services you agree to be bound by this Policy. If you do not agree to abide by the terms of this Policy, you are not authorized to use or access the Website and its Services. UPDATE: GDPR Statement For those in the EU who would like to have their collected data, as described above, compiled and sent to you, please reach out to FeelLikeAViking.com by email. We do not collect any data on any individual or organization that is not in a current business relationship with us. Non-members do have the right to control their cookie-based interaction in accordance with the above cookie policy. CONTACTING US If you have any questions about this Policy, please contact us. This document was last updated on May 6, 2022. Terms and conditions These terms of service (“Terms”, “Agreement”) are an agreement between Viking Alternative Medicine, LLC, ("Viking Alternative”, “us”, “we” or “our”) and you (“User”, “you” or “your”). This Agreement sets forth the general terms and conditions of your use of the https:// VikingAlternative.com website and any of its products or services (collectively, “Website” or “Services”). ACCOUNTS AND MEMBERSHIP If you create an account at the Website, you are responsible for maintaining the security of your account and you are fully responsible for all activities that occur under the account and any other actions taken in connection with it. Providing false contact information of any kind may result in the termination of your account. You must immediately notify us of any unauthorized uses of your account or any other breaches of security. We will not be liable for any acts or omissions by you, including any damages of any kind incurred as a result of such acts or omissions. We may suspend, disable, or delete your account (or any part thereof) if we determine that you have violated any provision of this Agreement or that your conduct or content would tend to damage our reputation and goodwill. If we delete your account for the foregoing reasons, you may not re-register for our Services. We may block your email address and Internet protocol address to prevent further registration. BILLING AND PAYMENTS You shall pay all fees or charges to your account in accordance with the fees, charges, and billing terms in effect at the time a fee or charge is due and payable. Where Services are offered on a free trial basis, payment may be required after the free trial period ends, and not when you enter your billing details (which may be required prior to the commencement of the free trial period). If auto-renewal is enabled for the Services you have subscribed for, you will be charged automatically in accordance with the term you selected. Sensitive and private data exchange happens over an SSL secured communication channel and is encrypted and protected with digital signatures, and our website is also in compliance with PCI vulnerability standards in order to create as secure of an environment as possible for Users. Scans for malware are performed on a regular basis for additional security and protection. If in our judgment, your purchase constitutes a high-risk transaction, we will require you to provide us with a copy of your valid government-issued photo identification, and possibly a copy of a recent bank statement for the credit or debit card used for the purchase. We reserve the right to change products and product pricing at any time. We also reserve the right to refuse any order you place with us. We may, in our sole discretion, limit or cancel quantities purchased per person, per household or per order. These restrictions may include orders placed by or under the same customer account, the same credit card, and/or orders that use the same billing and/or shipping address. In the event that we make a change to or cancel an order, we may attempt to notify you by contacting the e-mail and/or billing address/phone number provided at the time the order was made. REFUNDS AND CANCELATIONS No Refund Policy - Viking Alternative Medicine reserves the right to have a NO RETURN and NO REFUND policy. GUARANTEE OF SERVICES No Guarantee of Services Viking Alternative Medicine does not guarantee that any services or medications will be provided to you until you have undergone the full preliminary sign-up process and physician’s examination. At the physician’s discretion, you will be provided medications and/or services during your program at Viking Alternative Medicine. Accuracy of information ACCURACY OF INFORMATION Occasionally there may be information on our website that contains typographical errors, inaccuracies or omissions that may relate to product descriptions, pricing, availability, promotions, and offers. We reserve the right to correct any errors, inaccuracies, or omissions, and to change or update information or cancel orders if any information on the Website or on any related website is inaccurate at any time without prior notice (including after you have submitted your order). We undertake no obligation to update, amend or clarify information on the Website including, without limitation, pricing information, except as required by law. No specified update or refresh date applied on the Website should be taken to indicate that all information on the Website or on any related website has been modified or updated. BACKUPS We are not responsible for Content residing on the Website. In no event shall we be held liable for any loss of any Content. It is your sole responsibility to maintain an appropriate backup of your Content. Notwithstanding the foregoing, on some occasions and in certain circumstances, with absolutely no obligation, we may be able to restore some or all of your data that has been deleted as of a certain date and time when we may have backed up data for our own purposes. We make no guarantee that the data you need will be available. LINKS TO OTHER WEBSITES Although this Website may be linked to other websites, we are not, directly or indirectly, implying any approval, association, sponsorship, endorsement, or affiliation with any linked website, unless specifically stated herein. We are not responsible for examining or evaluating, and we do not warrant the offerings of, any businesses or individuals or the content of their websites. We do not assume any responsibility or liability for the actions, products, services, and content of any other third parties. You should carefully review the legal statements and other conditions of use of any website which you access through a link from this Website. Your linking to any other off-site pages or other websites is at your own risk. ADVERTISEMENTS During the use of the Website, you may enter into correspondence with or participate in promotions of advertisers or sponsors showing their goods or services through the Website. Any such activity, and any terms, conditions, warranties, or representations associated with such activity, are solely between you and the applicable third party. We shall have no liability, obligation or responsibility for any such correspondence, purchase, or promotion between you and any such third party. INTELLECTUAL PROPERTY RIGHTS This Agreement does not transfer from VikingAlternative.com to you any VikingAlternative.com or third-party intellectual property, and all right, title, and interest in and to such property will remain (as between the parties) solely with VikingAlternative.com. All trademarks, service marks, graphics, and logos used in connection with our website or Services are trademarks or registered trademarks of VikingAlternative.com or VikingAlternative.com licensors. Other trademarks, service marks, graphics, and logos used in connection with our website or Services may be the trademarks of other third parties. Your use of our Website and Services grants you no right or license to reproduce or otherwise use any VikingAlternative.com or third-party trademarks. DISCLAIMER OF WARRANTY You agree that your use of our Website or Services is solely at your own risk. You agree that such Service is provided on an “as-is” and “as available” basis. We expressly disclaim all warranties of any kind, whether express or implied, including but not limited to the implied warranties of merchantability, fitness for a particular purpose, and non-infringement. We make no warranty that the Services will meet your requirements, or that the Service will be uninterrupted, timely, secure, or error-free; nor do we make any warranty as to the results that may be obtained from the use of the Service or Products, or as to the accuracy or reliability of any information obtained through the Service or that defects in the Service will be corrected. You understand and agree that any material and/or data downloaded or otherwise obtained through the use of Service is done at your own discretion and risk and that you will be solely responsible for any damage to your computer system or loss of data that results from the download of such material and/or data. We make no warranty regarding any goods or services purchased or obtained through the Service or any transactions entered into through the Service. No advice or information, whether oral or written, obtained by you from us or through the Service shall create any warranty not expressly made herein. LIMITATION OF LIABILITY To the fullest extent permitted by applicable law, in no event will VikingAlternative.com, its affiliates, officers, directors, employees, agents, suppliers or licensors be liable to any person for (a): any indirect, incidental, special, punitive, cover or consequential damages (including, without limitation, damages for lost profits, revenue, sales, goodwill, use or content, impact on business, business interruption, loss of anticipated savings, loss of business opportunity) however caused, under any theory of liability, including, without limitation, contract, tort, warranty, breach of statutory duty, negligence or otherwise, even if VikingAlternative.com has been advised as to the possibility of such damages or could have foreseen such damages. To the maximum extent permitted by applicable law, the aggregate liability of VikingAlternative.com and its affiliates, officers, employees, agents, suppliers, and licensors, relating to the services will be limited to an amount greater of one dollar or any amounts actually paid in cash by you to VikingAlternative.com for the prior one-month period prior to the first event or occurrence giving rise to such liability. The limitations and exclusions also apply if this remedy does not fully compensate you for any losses or fails of its essential purpose. INDEMNIFICATION You agree to indemnify and hold Viking Alternative Medicine and its affiliates, directors, officers, employees, and agents harmless from and against any liabilities, losses, damages or costs, including reasonable attorneys’ fees, incurred in connection with or arising from any third-party allegations, claims, actions, disputes, or demands asserted against any of them as a result of or relating to your Content, your use of the Website or Services or any willful misconduct on your part. SEVERABILITY All rights and restrictions contained in this Agreement may be exercised and shall be applicable and binding only to the extent that they do not violate any applicable laws and are intended to be limited to the extent necessary so that they will not render this Agreement illegal, invalid or unenforceable. If any provision or portion of any provision of this Agreement shall be held to be illegal, invalid or unenforceable by a court of competent jurisdiction, it is the intention of the parties that the remaining provisions or portions thereof shall constitute their agreement with respect to the subject matter hereof, and all such remaining provisions or portions thereof shall remain in full force and effect. DISPUTE RESOLUTION The formation, interpretation, and performance of this Agreement and any disputes arising out of it shall be governed by the substantive and procedural laws of Missouri, in the United States without regard to its rules on conflicts or choice of law and, to the extent applicable, the laws of United States. The exclusive jurisdiction and venue for actions related to the subject matter hereof shall be the state and federal courts located in Missouri, United States, and you hereby submit to the personal jurisdiction of such courts. You hereby waive any right to a jury trial in any proceeding arising out of or related to this Agreement. The United Nations Convention on Contracts for the International Sale of Goods does not apply to this Agreement. CHANGES AND AMENDMENTS We reserve the right to modify this Agreement or its policies relating to the Website or Services at any time, effective upon posting of an updated version of this Agreement on the Website. When we do, we will revise the updated date at the bottom of this page. Continued use of the Website after any such changes shall constitute your consent to such changes. ACCEPTANCE OF THESE TERMS You acknowledge that you have read this Agreement and agree to all its terms and conditions. By using the Website or its Services you agree to be bound by this Agreement. If you do not agree to abide by the terms of this Agreement, you are not authorized to use or access the Website and its Services. If you have any questions about this Agreement, please contact us. This document was last updated on May 6, 2022. I agree to the Terms of Service HiddenInformed Consent for Hormone Replacement Therapy I agree to the Hormone Replacement Therapy policy.Because of the rapidly changing ideas about the safety and effectiveness of hormone therapy for anything other than birth control, I feel it is important to be sure that you have information about the risks and benefits of hormone therapy before you take the therapy we have discussed. HRT is approved by the FDA for prescribed deficiencies only. Using it for other symptoms or problems is considered “off-label” use and the liability is on the patient, not the doctor. When hormone levels are brought back to “normal” for your age there is much evidence that your overall health will benefit. HRT is the most effective treatment for hormone deficiencies. There may be other long-term beneficial effects of treatment. The medical frame of mind is always changing so it is important to discuss HRT with your doctor each year at your annual exam to find out what the latest information is. Please read the following and sign: I have discussed the reason for taking female/male sex hormones with my provider. I understand why he/she is prescribing them and the risks associated with taking hormones including but not limited to the possibility of an increased risk of breast or endometrial cancer, blood clotting, stroke, or heart attack. I understand that there are different risks if I take any HRT medication. I have discussed these risks and the reasons for taking them, with my doctor. I understand that my provider will do everything he/she knows to do to decrease and minimize the risks of HRT. I understand that there are no guarantees that these measures will be effective at preventing the negative side effects mentioned above or others that we do not yet know about. I accept the risks and unknowns of taking hormone therapy and wish to have my provider prescribe them for me.HiddenName First Middle Last OPTIONAL Credit Card Authorization FormHiddenCredit Card Type Master Card Visa Discover Amex HiddenCredit Card Number HiddenExpiration Datemm/yyyy HiddenSecurity Code HiddenName on Card First Middle Last HiddenBilling Address Street Address Address Line 2 City ALAKASAZARCACOCTDEDCFLGAGUHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDMPOHPuerto RicoOKORPAPRRISCSDTNTXUTVIVTVAWAWVAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanWIWY State ZIP Code HiddenCredit Card Policy I agree to the credit card policy policy.By signing this form, you give PureHRT 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 PureHRT to charge and sign your card for future transactions *** PureHRT reserves the right to have a NO RETURN AND NO REFUND POLICY.***HiddenCredit Card Policy I agree to the credit card policy policy.By signing this form, you give Viking Alternative Medicine 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 Viking Alternative Medicine to charge and sign your card for future transactions *** Viking Alternative Medicine reserves the right to have a NO RETURN AND NO REFUND POLICY.***
