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Order Form
CHINESE HERBAL WEIGHT LOSS TINCTURE


Mail / Fax Order Form

Fax: 760-735-8291


Ship to:

___________________________________________

___________________________________________

___________________________________________

___________________________________________


Please indicate form of payment, allow 4-6 weeks for personal checks.

CHECK _______

MONEY ORDER _______

CREDIT CARD _______ shipped in 24 hours

CREDIT CARD NUMBER ______________________________________

EXPIRATION DATE ___________________________________________

TYPE OF CARD _______________________________________________


DESCRIPTION QUANTITY UNIT COST


CHINESE HERBAL WEIGHT LOSS TINCTURE __________

$25.00 ___________

SUBTOTAL __________


Shipping & Handling Charges $6.95


                                                                                                  TOTAL DUE: _________

___________________________________________
Print name as it appears on Credit Card

___________________________________________
Signature


Mailing address:
Physicians' Choice Acupuncture
1556 Corte Capriana
Escondido, CA 92026