Online Order Form

Consumer Information:

Name:			
Full Address:		
			
			
Phone Number		
E-mail:


Order:

HealthPoint unit + Earclips
HealthPoint unit only
Earclips only

Note:
If ordering more than 5 units, please contact us by mail for special discount.
HealthPoint, P.O. Box 153, Provo, UT 84603-0153 U.S.A.


Payment:

Card Number: Expiration Date:
Note: At this point in time the information submitted by this form is not encripted. If you feel uncomfortable submitting your credit card information through this form, you may give us a phone number where we can reach you and a time period when it would be most convenient for you to be reached, or you can write us at the following address:
HealthPoint P.O. Box 153, Provo, UT 84603 
phone 		
time periods





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Last updated July 12, 1996
Created by SureSoft
Internet: Webmaster@SureSoft.com