Simply print and fill out the form below and fax to 1.818.758.7504
First Name:
Last Name:
Address:
City:
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Zip:
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Please print out this order form and mail it to the address on top. Please include your Check or Money Order.
Item Code
Description
Price
Quantity
WH001
3 months Supply / (90 capsules) (Save over 60% off the regular price)
$29.95
WH002
6 month supply (180 capsules) (Save over 68%)
$54.90
WH003
12 month supply (360 capsules) (Save over 72%)
$99.95
Name as on Card
CC# Street Address
CC# City
CC# State
CC# Zip
We will never automatically ship any more of our products to you or ever bill your credit card again unless you personally reorder.
Please select your shipping cost below:
USA Shipment - $3.95
Credit Card Number _________________________________________
Expiration Date _________________________________________
Signature: _________________________________________
(cardholder signature)