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The
Health Dimension Mall
Print, Fill-in
FAX / MAIL ORDER
FORM
PLEASE PRINT CLEARLY
Name______________________________________________
Attention_________________________________________
Street____________________________________________
City/State______________________ Zip______________
Telephone ( )________________________________
Specialty_________________________________________
________________________________________________
|_QTY_|_ITEM#_|__PRODUCT DESCRIPTION__|__AMOUNT__|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| | | | |
|_____|_______|_______________________|__________|
| ORDER TOTAL | |
|_____________________________________|__________|
| SALES TAX | |
|___[CA(8.25%) and IL(6.75%) ONLY)____|__________|
| | |
|_____________________HANDLING________|____5.95__|
| | |
|_____________________AMOUNT DUE______|__________|
PREPAYMENT IS REQUIRED
[ ] Check enclosed [ ] VISA
[ ] Mastercard [ ] Discorver Card [ ] American Express
For credit card orders please complete the following:
CREDIT CARD NO.______________________ EXPIRES:___/___
NAME ON THE CARD_____________________________________
CARDHOLDER SIGNATURE_________________________________
The
Health Dimension, Inc.
Email:healthdimension@yahoo.com
Home
Page: http://www.healthdimension.com
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