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For our records please fill out the following information: (a * signifies a required field)
Referred By: ( IF you were referred by a "Clear" Line Health Professional, please enter their name here)
Billing Name: *
Address: *
City, State, & Zip: * , * , & *
Contact Phone Numbers: *
E-mail address:
Shipping Address if different than billing address:
Yes, my shipping address is the same as my billing address.
Name:
Address:
City, State & Zip: , , &
Federal Tax Id# *
Type of Practice: Biofeedback Therapist Chiropractic Physician Integrative Holistic Physician Massage Therapist Medical Physician Naturopathic Physician Physical Therapist Reflexologist * If Other:
Degree: M.D. D.C. P.H.D. N.D. C.C.N. M.T. H.P. Other * If Other:
Payment Terms: Charge Credit Card
Type: Visa Mastercard American Express Discovercard *
Number: *
Expiration date: * xx/xx
Name on Card: *
*Authorized Signature: *
All orders must be either made through this site, E-mailed, Faxed or Mailed to us.
Future Body Sciences, Inc. P.O. Box 845 • Goshen, Indiana 46527-0845
E-mail: orders@futurebodysciences.com
Fax: 574-522-4889.
All prices are subject to change without notice
*must have signature on file that authorizes us to charge your card for all orders e-mailed or mailed to us.
Any Questions please contact Future Body Sciences, Inc. @ 574-825-0401
Email: assistant@futurebodysciences.com
