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Introductory Offer
Each Size:$17.50
Both Sizes:$30.00
Yes, I would like to try the AQUA-RELIEF(tm) Pad at the Special Introductory Price.

ORDER FORM

First Name:

 Last Name
Day Phone

 E-mail address:
Shipping Address (No P.O. Boxes):
 City
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 Country:
Zip Code:
Payment Type:
Visa Mastercard		 Credit Card Number:
Expiration Date & CCV Number
 Cardholder's Name
Signature (For Fax or Mail Order ONLY)
_____________________________________________
Items:
Back Pad ($17.50) Cervical Pad ($17.50) Both ($30.00)
Shipping (Please allow 1-2 weeks U.S. and 2-3 weeks other):
U.S. $7 each $9 both
Canada (UPS) $15 each $16 both
Europe (Parcel Post) $20 each $25 both (U.S. funds only)		 Total: Includes Shipping
Make sure you have filled in something for every field.


Options: Mail or Fax Order NO ON-LINE ORDERING
Print out Order Form and mail or fax to the number below or call the Toll Free number (U.S. Only)


Order Form Distributors

Regency Product
P.O. Box 64572
Los Angeles, CA 90064
Tel 323-266-2500 Fax 323-297-2599

Email david@regencyproducts.com