Wellmed LLC PO BOX 20046 Encino, CA 91416-0046
First Name:
Last Name:
Address:
City:
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Zip:
Phone:
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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.
Calculate Price based on Total Quantity Purchased
3 Pairs Only $10.99 each (Normally $19.99 each) Save 45% = $32.97 4 Pairs Only $ 9.99 each (Normally $19.99 each) Save 50% = $39.96 8 Pairs Only $ 8.99 each (Normally $19.99 each) Save 60% = $71.92
Name as on Card
CC# Street Address
CC# City
CC# State
CC# Zip
Important Note
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
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Expiration Date _________________________________________
Signature: _________________________________________
(cardholder signature)