Detoxamin Order Form

Note: Prices subject to change. Includes Dr. Saft's Personal Protocol, and FREE DVD.

PRINT this form: To purchase Detoxamin by CHECK or Credit Card, print the following form, fill out and mail with payment to: Dr. Geoffrey H. Saft, 21 Tamal Vista Blvd. Suite 210, Corte Madera, CA 94925. Or, if you prefer, you can instead fax your order, using credit card, to (415) 457-9370. For questions call (415) 927 8828.

 

Item	Regular Price	Discounted Price	Quantity	Total
Adult 15-pack	$119	$ 95
Adult 30-pack	$219	$189
Adult 60-pack	$418	$399
Adult 90-pack	$597	$567
Health Genesis	$29	$26
Vital Nutrition	$89	$79
Hvy Metal Urine Test	$75	$75
Hair Analysis	$75	$75
Child’s 30-pack	$209	$179
Child’s 60-pack	$398	$379
RepairAcell	$59.95	$54
Sub-total
Shipping				9
Grand Total

Credit Card Information: ( you may also pay by check )

Full Name
Street Address
City, State, Zip
Phone
Name on card
Credit Card #
Expiration Date
3 digit code	on back of credit card
Please circle one	Master Card      Visa

Shipping address, please fill out below:

Full Name
Street Address
City, State, Zip
Phone

Please sign below to acknowledge that you are ordering the above item(s) as indicated. MUST be signed.

Thank you.

Signature: ___________________________ Date: _____________