ORDER FORM

Books ~ Creams and Lotions ~ Blood Pressure Monitors ~ ID Jewelry

This order form will be transmitted over a secure connection.

Please provide the following contact information:

Full Name
Work Phone
Home Phone
E-mail

SHIP TO:
Full Name
Street Address
Address (cont.)
City, State, Zip

Please provide order information:

QTYDESCRIPTION
Control Diabetes in 6 Easy Steps  $12.95
Glucose Revolution:  Guide to Glycemic Index $15.95
Diabetic Low-Fat Meals in Minutes $19.95
Tell Me What to Eat If I Have Diabetes $11.99
Alternative & Complimentary Diabetes Care $14.95 
Atrac-Tain Cream, 5 oz tube  $7.95
Auto-Inflate Blood Pressure Monitor, MF-43  $47.95
Digital Blood Pressure Monitor (Manual), MF-33  $28.95

Special
Order
Form

ID Jewelry One-Sided $9.95, includes shipping
ID Jewelry Two-Sided $14.95, includes shipping

Shipping/Handling Costs:

Add $4.95 for shipping/handling charges.  US Shipments only.

Billing Information

Paying by Credit Card:

Cardholder Name
(as shown on credit card)

Card member Billing Address 
(if different than above)

Billing Address City/State/Zip
(if different than above)

Credit Card Account Number

Credit Card Expiration Date

 Month  Year   

CVV2/CVC2/CID Code

Paying by Personal Check/Money Order/Cashier's Check
  Please mail checks to:
          American Diabetes Services
          7301A W. Palmetto Park Road, Suite 101C
          Boca Raton, FL  33433

*Please note that payment is to be received prior to shipping. 

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Copyright 1999 American Diabetes Services, Inc. All rights reserved.
Revised: November 18, 2003