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Toll Free FAX Order
(888) 433-6726 • Phone Orders: (888) 433-4726
Or Mail this form to:
ScienceBased Health
3579 Highway 50, East
Carson City, NV 89701
Please help us know how you heard about ScienceBased
Health
Dr.
Edward D. Glinski
(UPIN#: 2205401) |
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30-DAY MONEY
BACK GUARANTEE: If for any reason you are not satisfied, simply
return any product within 30 days and receive your money back
(less S&H) - no questions asked!
NAME: (First, Middle, Last)
SHIPPING ADDRESS: (must be a street address for
deliveries)
MAILING ADDRESS: (if
different from shipping address)
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CITY |
STATE |
ZIP POSTAL CODE
+ 4
|
| DAY
PHONE |
EVENING
PHONE |
FAX
NUMBER
|
E-MAIL
|
|
Code#
|
Product Name
|
Qty
|
Price
|
Extended
Total
|
|
SN01
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OculaRxT
|
|
$36.95
|
|
|
200
|
OcularEssentialsT
|
|
$16.50
|
|
|
210
|
MaculaRxT
Suite
|
|
$30.95
|
|
|
220
|
MaculaRxT
Plus
|
|
$78.95
|
|
|
230
|
Optic
Nerve FormulaT
|
|
$78.95
|
|
|
240
|
HydroEyeT
|
|
$39.50
|
|
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Payment Type: Cash Check... MasterCard ... Visa
AmericanExpress ...
Discover
... Check Draft* |
|
Sub Total |
|
|
Credit Card Account
Number |
Expiration
Date |
|
|
Cardholder Name |
Plus Shipping
& Handling |
|
Your Signature
and Date |
TOTAL |
*AUTO BANK DRAFT AGREEMENT:
Voided check must be attached. Do not use deposit slip. I hereby authorize
ScienceBased Health, or its authorized agent in accordance with this agreement,
to initiate debit/credit entries to my/our checking or charge account
as indicated above. The authority is to remain in full force and effect
until ScienceBased Health has received written notification from me/us
of its termination, in such a manner as to afford NWC reasonable opportunity
to act on it, pursuant to this Agreement.
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