Hemorrhoid Treatment Pills Mail Order Form

Simply Print and Mail OR Fax
Toll Free Fax: 1-888-777-0038
Must be 18 years or older to purchase
Make Checks Payable to: Red Door Marketing Ltd.
Please fill out the following form. Check the box next to the product
you wish to order, and then mark the quantity you wish to order.

Product
Quantity
Price
Amount
Hemorrhoid Treatment Pills 5months
  
$ 197.97
 $
Hemorrhoid Treatment Pills 3months  
$ 138.97
 $
Hemorrhoid Treatment Pills 2months  
$ 93.97
 $
Hemorrhoid Treatment Pills 1month
  
$ 49.97
 $

All prices are in US Funds.

Shipping charges: US = $10.00
Canada = $10.00
International = $19.95
Sub-Total
 $
+ Shipping
 $
+ Tax
 $
Total Order
$
   

Thank you for your Order.

Additional Information and/or
comments:

Credit Card Number (no spaces)

__________________________________________

Expiry Date_________________________________

CVV2#_____________________________________
(the number on the back of the card in the signature bar)

Card Type__________________________________

Make checks payable to:

Name:_____________________________________

Address:___________________________________

__________________________________________

__________________________________________

Phone:____________________________________

E-Mail:____________________________________