Order Form - Living With Shingles

Unique Enterprises 2330 Kings Point Drive FAX - 888-268-2795 Email: skinrlfctr@aol.com	Print This Page to MAIL or FAX Your Order
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MAGNETIC THERAPY PRODUCTS FAX ORDER FORM

Name :
Name (as appears on credit card):
Phone:		Fax:		Email:
Address:

City				State:	Zip:
circle your card type	Mastercard	Discover	Amex	Visa	Check/Money Order
Credit Card #:_____________________________________					Exp. Date: ____/____

Item	Product	Price Ea.	Quantity	Total Cost
S1	Soother 1	$42.97
	Soother 1 S/H per Item	$7.70
S2	Soother 2	$190.50
	Soother 2 S/H per Item	$11.70
S3	Soother 3	$930.50
	Soother 3 S/H per Item	$60.00
Total

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Thank You For Your Patronage