Colon Cancer Self Screening Test ( Main Page)
Please print this form and mail to:
HEALTHCARE INTERNATIONAL CORPORATION SHIP TO/GIFT TO: NAME: ____________________________________ Address: _______________________________________________________ City: __________________
State: ____________
Zip: __________ Phone: ___________________ Fax: ________________
E-mail: __________
3165 VENARD ROAD
DOWNERS GROVE, ILLINOIS 60515, U.S.A
PHONE: 630-963-3573
E-MAIL: TERSYLAS@AOL.COM
1 Pack = 3 TESTS = $8.00
Quantity (# of Packs): ______ x $8.00 = Total Price $________
Shipping & handling included within U.S.A. and its territories and military bases.
Send Check or money order or charge to VISA or MASTERCARD
Card Number: __________________________ Expiration: _______________
Signature: _____________________________ Date: ___________________