PharmWest Order Form |
| delivery information: |
Call or Fax mail orders to:
|
|
| Name | _____________________________ |
Ireland 00-353-46-943-7317 (tel)
|
| Address | _____________________________ |
Ireland 00-353-46-943-7310 (fax)
|
| _____________________________ |
USA 001-310-301-4015 (tel)
|
|
| _____________________________ |
USA 001-310-577-0296 (fax)
|
|
| Post Code | _____________________________ |
Email mpurdy@iol.ie (Ireland)
|
| Country | _____________________________ |
Order online at:
www.pharmwest.com
|
| Phone | _____________________________ |
PharmWest, 4640 Admiralty Way, Suite 423
|
| Fax | _____________________________ |
Marina Del Rey, CA 90292 (USA)
|
Visa/MasterCard/Amex #: ________________________________________Exp. Date: _________ |
| Signature:
______________________________________________________________________
|
|
quantity
|
product
|
US$
|
GB£* |
total
|
| Natural Hormones | ||||
| __________ | Melatonin (3mg x 60 tablets) | $15.00 | £7.20 | $________ |
| __________ | Pro Body Cream (2 oz) | $32.00 | £15.30 | $________ |
| __________ | PhytoEstrogen Body Cream (2 oz) | $39.00 | £18.65 | $________ |
| __________ | DHEA (25mg x 180 tablets) not available in all countries | $44.00 | £21.05 | $________ |
| _________ | Pregnenolone (30mg x 150 capsules) | $75.00 | £35.90 | $________ |
| _________ | 5-Hydroxy Tryptophan (50mg x 60 capsules) | $50.00 | £23.95 | $________ |
| Skin Care | ||||
| __________ | Multi-Active Eye Treatment (1/2 oz) | $19.95 | £9.55 | $________ |
| __________ | Extra Firming Facial Serum (1 oz) | $29.95 | £14.35 | $________ |
| __________ | Rejuvenating Facial Mask (2 oz) | $22.95 | £11.00 | $________ |
| __________ | Body Lotion (6 oz) | $29.95 | £14.35 | $________ |
| Pain DefenseTM | ||||
| __________ | Pain Defense™ - Relief Roll-On (2 oz.) | $19.95 | £9.55 | $________ |
| __________ | Advanced Defense™ - Joint & Muscle Formula (60 caps) | $29.95 | £14.35 | $________ |
| __________ | Combination (includes 1 Roll-On & 1 Joint & Muscle Formula) | $42.50 | £20.35 | $________ |
|
Subtotal
|
$___________ | ||
|
Shipping & Handling
|
$ 6.50 (£3.10) | ||
|
(California residents add 8.25%
sales tax) $________ TOTAL (in US$)
|
$___________ | ||
|
Note: customer will be charged in US
dollars, conversion price is approximate.
GB£ is calculated on the basis of £1.00 to $2.09. Payment can be made by International Money Order in US$ or by Credit Card. |
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Copyright 2007 PharmWest, Inc.
PharmWest
The Natural Beauty Technology Company
ORDER FORM
