Simply print and fill out the form below and fax to 1.818.348.2202
First Name:
Last Name:
Address:
City:
State:
Zip:
Phone:
Email:
Please print out this order form and mail it to the address on top. Please include your Check or Money Order.
Item Code
Description
Price
Quantity
TG001
45 day Therapy-G
$43.75
TG002
90 day supply of Therapy-G (Includes special FREE Therapy-G Vitamins)
$69.90
Name as on Card
CC# Street Address
CC# City
CC# State
CC# Zip
We will never automatically ship any more of our products to you or ever bill your credit card again unless you personally reorder.
Please select your shipping cost below:
USA Shipment - $3.95
Credit Card Number _________________________________________
Expiration Date _________________________________________
Signature: _________________________________________
(cardholder signature)