PRINT AND FILL THIS OUT TO USE AS A GUIDE

 Please ship my order to: Name
 Street Address
 City/State/Zip
 Daytime Phone (       )                                 E-mail Address:
 VISA          MasterCard          Discover             American Express                                                                        Card #                                                                               Exp        / 
 Name, as it appears on credit card:
 Contact, if other than above: Name                                        Phone/Email
Item Code Description Price per unit Unit Weight Qty Total Weight Total Price
             
             
             
             
             
             
             
             
             
             
             
             

TOTAL    

     $

Ship via:  FedEx Ground     FedEx 2nd Day        FedEx Next Day Air      Other__________  

      PRODUCT TOTAL PRICE $___________               

                            SHIPPING  $ ___________               

    TOTAL  $ ___________                

            MasterCard     Discover Business Services

Call: 800-633-5550 (M-F 8:00 AM - 4:30 PM Central)

Fax: 763-550-2022

Mail: Med-Diet Labs, Inc. 3600 Holly Lane, Suite 80 Plymouth, MN 55447