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Please Print and sign order.  All unsigned orders will be mailed back to sender!  Money, Money orders or certified funds only.  No personal checks.

Please use an additional piece of paper if order is larger.


      Price               Quantity Free Shipping!
CC =  
Gauge =  
Length =  
___________ ________


Grand Total $ 

Please PRINT this form and fill it in by pen.  To avoid delays please send cash, cashiers check or money order.  We ship within 24 hours from receipt of your order.  Send To:        

Androusa Inc., Box 6352, Colorado Springs, CO  80934                                                                

Your Shipping Info:

City, State, Zip  

Must Be signed to process order!

*When we receive funds we will email you and let you know the expected arrival date.

DO NOT order syringes if they are not legal in your area, or where you are having them shipped them to.  You must be over the age of 18yrs to order, you are entirely responsible for knowing your state/county/local/city ordinances, not us. You are responsible for any circumstances that result in your actions pertaining to the ordering of these medical supplies,  By signing here Your are agreeing to the above terms and conditions X_________________date: _______________