1. Consultation PLUS Remedy Mix $25
   
2. Choose Your Own Remedy Mix (up to 7 remedies)$15
   
3. Mothers Free Offer May 2008: No Charge!
   

Payment Form
Credit Card or Direct Deposit

Enter your credit card billing information ( * = required ) .  This must match your credit card statement address.
(We will use this address for shipping unless you enter a different address in the Shipping Address section):

Title	Mr. Ms. Dr. Mrs. Miss Prof. Rev. Sgt. Capt. Maj. Col. Other
*Name
Organization
*Street Address
Address (cont.)
*City
*State/Province
*Zip/Postal Code
Country
Home Phone
Work Phone
FAX
*E-mail

*Preferred payment method:	Direct bank deposit Credit card Cheque per post
*Credit Card	VISA BankCard MasterCard American Express
*Cardholder Name
*Card Number (enter digits only -- no spaces or letters)

**   We will contact you separately, as a security measure, in order to confirm the card expiration date and the 3 or 4 digit card security code.

**   Please proceed to the bottom of the page to view Direct Deposit (bank) and postal address details (for cheques)

**   Please note that shipment will be facilitated once payment is cleared.

Shipping Address (if different than billing address):

Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country

Your charge total (we will verify and adjust your total before putting through your charge):

Your charge total (we will verify and adjust your total before putting through your charge):

  

Please enter the amount you authorise to be charged to your card or that you will be transferring:

**   After you click Submit Form, please wait to be taken to a confirmation page.  
If you get an error instead, that means the form did not get forwarded to us.  Please submit again.