| Name: ___________________________ | Phone: _______________ |
| Street: ________________________________________ |
| City: _____________ State: ____________ Zip Code: __________ |
| Eamil: _____________________________ |
| Credit Card No: ___________________________________ | Exp Date: ___ / ___ (mm/yyyy) |
If you like to pay by credit card, please fill out the above information, then print a copy and fax it to us. If you like to pay by check or money order, please make check payable to Natural Healing Plus
2735 Carson Street, Suite B, Lakewood, CA 90712Fax: (562) 468-0198 |