LAVitamin.com
Name _____________________________________ Phone# ________________________
Billing Street Address¡G ___________________________________________________
City¡G ___________________________ State ¡G ___________________ zip¡G ______________
Ship to Address¡G _______________________________________________________
City¡G ___________________________ State ¡G __________________ zip¡G ______________
Eamil¡G _________________________________________
Credit Card No¡G ____________________________________
Exp date¡G_____(¤ë )_______ (¦~) Security Code(3-digits-on back of card): _______
If you want to pay with a credit card¡Aplease enter your credit card number, expiration date & security code.¡CIf you want ot pay with a chack or money order, please send it with this page to

Natural Healing Plus
3040 S. Hacienda Blvd., Hacienda Hts., CA 91745
Telephone: (562) 429-6888     Fax Number¡G (562) 366-9355