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Please
print and fill out this form completely and fax it to: (888)-610-5761
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4 MONTH SUPPLY |
CleanseRX System
x 4 -$70 Savings |
$249.99 |
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3 MONTH SUPPLY |
CleanseRX System
x 3 -$40 Savings |
$199.99 |
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2 MONTH SUPPLY |
CleanseRX System
x 2 -$15 Savings |
$144.98 |
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1 MONTH SUPPLY |
CleanseRX System x 1 |
$79.99 |
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4 MONTH SUPPLY |
CleanseRX Phase2
x 4 -$30 Savings |
$169.99 |
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3 MONTH SUPPLY |
CleanseRX Phase2
x 3 -$15 Savings |
$134.99 |
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2 MONTH SUPPLY |
CleanseRX Phase2
x 2 -$5 Savings |
$94.99 |
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1 MONTH SUPPLY |
CleanseRX Phase2 x 1 |
$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 CleanseRX 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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