Order form

Health Resources https://www.zhealthinfo.com
4282 West 10000 South..................................... . Telephone 801-465-4949 or toll free 888-468-4950
Payson, UT 84651............................................ . Call or E-mail if need fax number (too much spam to list)
E-mail: Lynne@zhealthinfo.com

Please print this form, fill it out by hand, and mail it to the address above. Make checks payable to:
Health Resources. Don't hesitate to contact us if you have any problems filling out (or printing) this form.
Date:_________________
ORDERED BY
Your Name ________________________ MAIL TO (if different)

Address __________________________ Name___________________________

City ____________________________ Address__________________________

State, Zip _________________________ City_____________________________

Telephone (_____) __________________ State, Zip_________________________

E-mail address_______________________

<> PAYMENT INFORMATION          Select one:
    ___Check/Money order
    ___Visa                                 Account Number __________________________________________
    ___ MasterCard                  Account Name and/or address ___________________________(if different than above)
    ___ American Express        Expiration(mm/yy) ________________________
    ___ Discover
   ___ Diner's Card
3 digit verification number on back by signature after the last set of 4 numbers (VISA, M/C & Discover)________(CV Code)
for American Express use the 4 digit verification number printed on front after the last 3 imprinted numbers _____
                                        Signature   ______________________________

Item #	Qty	Description..................................................	Price each	Total Price
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.	.	.	S&H (minimum $6.00)	.
			Insurance & tracking	$1.20
			Total due

All prices are in US dollars, and all payments must be made in US dollars.

Health Resources Minimum Shipping & Handling is $6.00
There are so many variances that you need to e-mail us or use our shopping cart to determine shipping, keeping in mind to allow for packaging. Lynne@zhealthinfo.com

Please note any SPECIAL INSTRUCTIONS below or on back.