Quantity ___________ @ $24.95 #_____
@ $24.95 ________
Shipping and Handling (each)
#_____
@ $4.95 ________
Buy Three and Shipping and Handling is FREE*
Make check payable to Physicians Direct¨ Total
$ ______ . ____
Mail this form with check or credit card info or fax
form with credit card info to:
Physicians Direct¨
7350 Sandlake Commons Blvd. Suite
2217
Orlando, FL 32819
Fax to 407-363-9538
Name________________________________Email ________________________________
Day Phone ________________ Evening Phone________________ Fax________________
Address Credit Card Statement is sent to:
Name___________________________________Company_______________________(optional)
Address_______________________________________________________________________
City________________ State________Zip Code_____________________ Country___________
Ship To Address if different than above:
Name___________________________________Company_______________________(optional)
Address_______________________________________________________________________
City________________ State________Zip Code_____________________ Country___________
Credit Card Information:
Type : qVisa qMasterCard Visa qDiscover Visa qAMEX
Name exactly as typed on card: __________________________________________________
Card # __________________________________________Expiration Date _______________
Visa# last 3 digits on back near signature________________ Amex 4 digits above card#______
To learn about The Smartest,
Healthiest, Safest, Easiest, and Most Effective Way To Lose Weightª Or Lower
Your Cholesterol Naturally –visit Physicians Direct¨ at www.fastweightloss-101.com
To learn about "The Best
Health Insurance You Can BuyÉ In A Bottle¨" –visit Physicians
Select¨ at www.physicians-select.com
(Dr. LevineÕs Ultimate Antioxidant Formulaª)
To Learn about the ultimate in sun protection –visit Physicians
Direct¨ at www.ultimate-skin-care.com
To Learn about
the ultimate in anti-aging creams–visit Physicians Direct¨ at www.ultimate-skin-care.com
*
Shipping free within the 48 contiguous U.S. States