Herbal Healthline Mail and Fax Order Form

Please circle selected products and complete the totals down the right hand column.

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HERBAL ENHANCEMENT:
1 Month
2 Month
3 Month
4 Month
6 Month
12 Month
TOTAL
OptimRx - Herbal Penis Enlargement Pills
$59.99
$109.95
$159.95
$200.00
$300.00
$575.88
 $
OptiPatch - Penis Enlargement Patch
$59.99
$109.95
3+1 Free: $159.95
$300.00
$575.88
 $
Majestic - Herbal Breast Enhancement Pills
$49.95
$89.95
$129.95
$160.00
$240.00
$455.88
 $
Lush - Breast Enhancement Patches
$59.99
$109.95
$159.95
$199.99
$249.99
$499.98
 $
Eden - Herbal Viagra for Women
$49.95
$89.95
$129.95
$160.00
$240.00
$455.88
 $
Eros - Herbal sex-enhancer Men
$49.95
$89.95
$129.95
$160.00
$240.00
$455.88
 $
OptimOil - Erection Enhancing Oil
$59.95
$109.95
$159.95
$200.00
$300.00
$575.88
 $
Trima - Breast Reduction for Women
$69.96
$128.96
$183.87
$234.67
4+1 Free
$299.96
$549.92
 $
TrimanX - Breast Reduction for Men
$69.96
$128.96
$183.87
$234.67
4+1 Free
$299.96
$549.92
 $
 
HERBAL REMEDIES/SOLUTIONS:  
Serenitee - PMS Solution
$29.99
$54.95
$79.99
$100.00
$150.00
$300.00
 $
Regain - Hair Growth
!
!
$129.99
!
$240.00
$455.88
 $
Refresh - Acne Control
$39.99
$74.95
$109.95
$140.00
$210.00
$395.88
 $
Gen-Rx - Cold Sore Simplex
$39.99
$74.95
$109.95
$140.00
$210.00
$395.88
 $
DreamEasy - Insomnia Sleep Aid
$39.99
$74.95
$109.95
$140.00
$210.00
$395.88
 $
Hemotrol - Hemorrhoid Treatment 
$49.97
$93.97
$138.97
$159.95
$197.97
$395.94
 $
Date: Time:  ***ALL PRICES ARE US DOLLARS***
Credit Card Information:
Type:   

Shipping

USA & Canada
$9.95 - 3-5 days
$14.95 - 2-3 days

International
$19.95 - 7-10 days

    SUB-TOTAL
$
No:   
Exp. Date:     SHIPPING TOTAL
$
CVV2*   
Name:    GRAND TOTAL
$
Address  :
Apt No:   

Please send checks/money orders payable to:

PO BOX 294
CASSIDY
BC V0R 1H0
CANADA
Toll Free Phone: 1 888 777 4401
Toll Free Fax: 1 888 777 0038

CustomeCare@HerbalHealthline.com
City/Town:   
State:    
Zip/Postal:   
Country:   
Phone:   
E-mail:   
ADDITIONAL INFORMATION/COMMENTS: