Order Form
CHINESE HERBAL WEIGHT LOSS TINCTURE
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Mail / Fax Order Form
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Fax: 760-735-8291
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Ship to:
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Please indicate form of payment, allow 4-6 weeks for personal checks.
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CHECK _______
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MONEY ORDER _______
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CREDIT CARD _______ shipped in 24 hours
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CREDIT CARD NUMBER ______________________________________
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EXPIRATION DATE ___________________________________________
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TYPE OF CARD _______________________________________________
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DESCRIPTION QUANTITY UNIT COST
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CHINESE HERBAL WEIGHT LOSS TINCTURE __________
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SUBTOTAL __________
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Shipping & Handling Charges $6.95
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TOTAL DUE: _________
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Print name as it appears on Credit Card
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Signature
Mailing address:
Physicians' Choice Acupuncture
1556 Corte Capriana
Escondido, CA 92026