Yeast Consulting Services Order Form

Order Form

Use this Form for Postal Mail or Phone Orders only!
For secure online ordering click here.

Description	Cost	Total Cost
Information Packet (180 pages) includes $6 for shipping and handling to US addresses	$26
Information Packet (180 pages) includes $12 for shipping and handling for addresses in other countries than the US	$32
Phone Consult (up to 30 minutes; $1/min thereafter)	$30
Review Medical Records (sent by fax or postal mail)	$1 per page
Patient Evaluation (with one revision; sent to patient and doctor)	$200/report
TOTAL U.S. Dollars:

* NAME

* ADDRESS

* CITY

* STATE * ZIP CODE

* TELEPHONE NUMBER

* E-MAIL ADDRESS

* required fields

Visa Master Card Discover Card American Express

Account # Exp. Date (example: 06/2007)

If the credit card owner is different from above, please fill in the name as it appears on the card plus the billing address below:

Thank You for your order!