| ChiroVantage
Product Order Form PRINT & FAX TO 519-538-4814 OR MAIL TO THE ADDRESS BELOW ChiroVantage, 62 Gray Avenue Meaford, Ontario, Canada N4L 1C4 |
| NAME |
| ADDRESS |
| CITY |
| STATE / PROVINCE |
| ZIP / POSTAL CODE |
| COUNTRY |
| PHONE |
| FAX |
| VISA # |
| MASTERCARD # |
| CARDHOLDER NAME |
| EXPIRY DATE |
| TOTAL ORDER |
| Prices in U.S. Funds. SHIPPING & HANDLING: $35. ALL ORDERS |
| PRODUCT | PRICE | QUANTITY | TOTAL |
| Chiro Curl Pillow | $28.95 | ||
| Chiro Curl Pillow Volume Discount Deal (over 12) | $21. | ||
| Kids Copy & Colour Kit | $15. | ||
| Pair of Pregnancy Plus Pillows with Memory Foam | $179. | ||
| Pregnancy Plus Pillow Set with Memory Foam Plus 1 Chiro Curl |
$199. | ||
| For pregnancy pillows choose: (circle one) Blue / Taupe / Grey / Black / Burgundy |
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