Life Remedy Inc.

Inside Life Remedy

Order form

Products

Skin-cap

Blue cap

Asbrip

Diamel

Kalsis

Feedback

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LIFE REMEDY ORDER FORM

Tel:1-718-830-9456
Fax: 1-718-830-9640
Tel (only in US): 1-800-731-2666

ORDERED BY (Your permanent mailing address.)

Name:
Family Name:
Address:
City:
State: :
Zip Code:
Country:
Phone Number:
Fax Number:
E-Mail:

PRODUCT	PRICE	QTY
ASBRIP Syrup	US$ 9 - per unit
VIUSID 90 Sachets of 0,16 oz	US$ 90 - per unit
VIUSID 21 Sachets of 0,16 oz	US$ 20 - per unit
BLUE-CAP Shampoo	US$ 17 - per unit
BLUE-CAP Cream	US$ 23 - per unit
BLUE-CAP Spray	US$ 35 - per unit
SKIN-CAP Shampoo	US$ 17 - per unit
SKIN-CAP Cream	US$ 23 - per unit
SKIN-CAP Spray	US$ 35 - per unit
DIAMEL 90 Capsules	US$ 30 - per unit
DIAMEL Syrup	US$ 20 - per unit
HERPIGEN Intimo	US$ 30 - per unit
HERPIGEN Labial	US$ 10 - per unit
KALSIS 90 Capsules	US$ 39.95 - per unit
FOLREX Cream	US$ 14.95 - per unit

Shipment - 6.0 $

Your order will be shipped once we receive the corresponding payment.

Approximate delivery time: three/four days!

ONLINE CARD PAYMENT

Accepted Cards:

Card Number :

Expiration Date:	Month
	Year

If you give us your e-mail address, we'll notifie you the payment when it's been done:

Name as it appears in the credit card:

PLEASE CHECK ALL THE DETAILS Once you have clicked on the "PAY" button, wait for response. Please don't click the "BACK" button or the "STOP" button of your browser until you have received a response. If you do so, you won't be able to see the transaction result. This is a secure transaction.