Please print out this form, complete the top portion, have your Health Care Provider (Medical Doctor, Chiropractor, Dentist, Podiatrist, Nurse Practitioner, Physicians Assistant, Ph.D., Physical Therapist, Doctor of Acupuncture or Doctor of Osteopathy) sign it and mail or fax it in today.

(Please Print)
Patient's Name_______________________________________________________

Address ___________________________________________________________

City ______________________ State _____________________ Zip ___________

Day Phone________________________Evening Phone _____________________

E-mail_____________________________Fax _____________________________

Method of Payment: $99 S/H $6 Express Overnight $15
Check Enclosed (US Currency Only) Mastercard Visa Discover

Card #________________________________________Exp. Date _____________

Name on Credit Card__________________________________________________

Credit Card Billing Address_________________________________ Zip _________

Signature ________________________________________________________

Name of your licensed health care practitioner _______________________________

License # __________________________________________________________

Dr's address ________________________________________________________

City_______________________State____________________Zip ____________

Doctor's Signature __________________________________________________

Print out and mail/fax form to: