Millennium Health LLc

Fax Order Form send to (1)208-361-0460

If you prefer to fax your order then Print this page and send this form to the above number

Quantity
Product
Price
Subtotal
   
$
 
       
       
Shipping and handling
$ 8.95
Countries outside USA/Canada/Europe/Australia/NZ:
Please add US$ 7.00 postal insurance to cover against lost/damaged goods. We cannot replace or refund your order unless this insurance is added to your total payment.
(Only applicable OUTSIDE USA/Canada/Europe/Australia/NZ)
TOTAL
 

All fields must be filled in for order to be processed (BLOCK, capital letters please)

Name  _________________________________________________________________

Address ________________________________________________________________

City ___________________________________________________________________

State  ____________Postal/Zip ___________ Country _______________________

Telephone _____________________Email ________________________________

Card Number _______________________________________________________

Card Verification Number ________ (last 3 numbers on the back of the card)

Card type (Visa/Master) ____________ Expiry Date_______US$__________

Card holder billing address if different from above, otherwise leave blank:

___________________________________________________________

___________________________________________________________

Signature ______________________________ Print this page


Allow up to 5 - 10 days for delivery
Fax the complete form to 208-361-0460
Your payment receipt and order confirmation will be sent to your email address
Thank you for your custom!