HealthDesigns Order Form (print this page)  www.healthdesigns.com

To: HealthDesigns International

Fax: 1.847.628.0348 (Voice toll free 1.888.311.1146 or 574.875.4653)

Re: Ordering Products/Test

Name: __________________________________

Phone:___________________________

Fax:    ___________________________

Billing Address:______________________________________
                             ______________________________________
                              ______________________________________

Mailing Address:______________________________________
                             ______________________________________
                              ______________________________________

Email:___________________________

Credit Card: Please circle one of these:

1. Visa
2. Mastercard
3. Discover
4. American Express

• Credit Card Number:___________________________
• Expiration Date:____________
• Name as it appears on your credit card:___________________________
• Signature:______________________________________
• I am authorizing HealthDesigns International to charge my credit card.