Health Resources                                                 http://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)
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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.