ONLINE ORDER FORM for Kate's Grocery Delivery Service

Customer Name

Street Address

City

Nearest Intersection

Phone Number

E-Mail Address

Store Preference

Date of Delivery (mm/dd/yy)

GROCERY ORDER INFORMATION

Example
Unit (Ea/Lb)
Size/Pkg ct
Item
Quantity
Brand/Location
Lb.
Bulk
Broccoli Crown
2
Produce
Ea.
6 ct.
Toilet Paper
1
Charmin
Ea.
Loaf
Wheat Bread
2
Aunt Millies
Lb.
Bulk
Mustard Potato Salad
1
Deli

GROCERY ORDER FORM

Type of bag preferred:

Please check the box if you want item substitution

Order #
Unit Ea/LB
Size/Pkg ct
Item/Flavor
Quantity
Brand / Location
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
Order #
Unit Ea/LB
Size/Pkg ct
Item/Flavor
Quantity
Brand / Location

PRESCRIPTION PICK-UP INFORMATION
Patient Name:
Prescribing Doctor:
Date of Birth (mm/dd/yy):
1. Name of Med / Pill Count / Milligrams
2. Name of Med / Pill Count / Milligrams
3. Name of Med / Pill Count / Milligrams

Other specific directions or messages

If you have any questions, please do not hesitate to contact me via:
Phone 616-520-5019 or Email: kate@katesgds.com

I will contact you to confirm the delivery day/time within 1 hour.

Thank you for your order!