Order Forms

We can only accept your credit card numbers by telephone (toll free: 877-342-3907, local: 503-494-7708, fax: 503-494-4202) or if you prefer we can call you. Please fill out the form below and mark the box as to your preference. If you have ordered from us recently We may have the card #, if so, mark that box. Thank You!

Date:

mm/dd/yy

First Name:

Middle Initial:

Last Name:

Degree:

E-mail:

Please make sure to give us your e-mail as we routinely acknowledge receipt of your order via return e-mail.

What would you like us to do when your order comes?:

Inform you via E-mail?

Call you?

Ship it to you?

If you would like us to call you when the order comes, please provide a phone number where we can contact you

Telephone Number:

If you would like us to ship the order, please provide your address

Address 1:

Address 2:

City:

State:

Zip Code:

Please check appropriate box

Credit Card Information:

You have ordered from us and we have your Credti Card#

You will call with Credit card #

You will fax Credit Card#

You want us to call you for Credit Card #

If you would like us to call you for the Credit Card #, please provide a phone number where we can contact you

Phone Number:

Order Information

Purchase Order # (if available):

Where should we send the receipt?:

Attention of:

Address 1:

Address 2:

City:

State:

Zip Code:

Order or Message:

Please enter your message or order here

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