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Body Detoxification Foot Patch Order FormPlease print and mail or fax this form with payment to: |
FREE priority mail to all US locations.
For shipment
to foreign countries please add the "if Global" amount indicated.
| Product Description | Unit Cost | Quantity | Sub Total |
| Sample of 4 Takara Foot Patches + $5 if Global | $ 13.50 | ||
| 1 Box of 36 Takara Foot Patches + $12 if Global | $ 73.95 | ||
| 2 Boxes (72 count) Takara Foot Patches + $18 if Global | $ 135.95 | ||
| 5 Boxes (180 count) Takara Foot Patches + $18 if Global | $ 333.95 | ||
| 10 Boxes (360 count) Takara Foot Patches + $30 if Global | $ 633.95 |
Total Order Amount $ __________________________Date: _________________________
My Payment Method is: ____ Cash ____ Check ____ Money Order ____ Credit Card
Card # ______________________________________________ Exp _______ CVC _______
Card Holders Signature ________________________________________________________
Full Name: __________________________________ Phone(________) _________________
Billing Address:____________________________________________ Suite # ____________
City: ________________________________ State:________________ Zip: ______________
If Different from billing address :
Full Name: __________________________________ Phone(________) _________________
Shipping Address:____________________________________________ Suite # ____________
City: ________________________________ State:________________ Zip: ______________
Email Address:________________________________________________________________