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Please
print and fill out this form completely and fax it to: (888)-610-5761
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6 MONTH SUPPLY |
Cleansepatch
x 6 boxes -$113 Savings |
$199.99 |
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5 MONTH SUPPLY |
Cleansepatch
x 5 boxes -$70 Savings |
$179.99 |
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4 MONTH SUPPLY |
Cleansepatch
x 4 boxes -$45 Savings |
$154.99 |
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3 MONTH SUPPLY |
Cleansepatch
x 3 boxes -$25 Savings |
$124.99 |
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2 MONTH SUPPLY |
Cleansepatch
x 2 boxes -$10 Savings |
$89.98 |
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1 MONTH SUPPLY |
Cleansepatch x 1 box |
$49.99 |
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Shipping
Information:
Name: |
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Address: |
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City/State/Zip: |
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Country: |
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Telephone: |
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Email
Address: |
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Amount
Enclosed:
Write
in the amount for the Cleansepatch supply you chose: |
$ |
Shipping
and Handling: |
$
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TOTAL
ORDER IN US DOLLARS: |
$ |
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Amount Enclosed
Type
of Credit Card: |
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Visa |
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Mastercard |
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Discover |
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American
Express |
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Credit
Card Number: |
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Expiration
Date: |
_______Month
_______Year |
Security
Code:
(3 or 4 digit number on back of card) |
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Signature: |
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