HealthWisdom Postal Order Form

HealthWisdom.com Postal Mail Order Form

Name:	____________________________
Phone Number:	____________________________
Email Address:	____________________________

Shipping Address
Address:	____________________________
City, State Zip	____________________________

Billing Address (if different from shipping address)
Name:	____________________________
Address:	____________________________
City, State Zip:	____________________________

Product	Quantity	Unit Price	Total Price





Sub Total:
Shipping: (Please note current shipping pricing on the site or call us.)
Total Price:

Payment Information:

___ Credit Card ___ Personal Check ___ Money Order ___ Cash

Credit Card Information:

__ Visa __ MC __ AMEX __ Discover

Credit Card Number:_____________________ Exp. Date: _______