Order Form to Print – Horizon Macular Health

Horizon Complete ORDER FORM

STEP 1: CONTACT INFORMATION
Name*:
Address*:
City*:
State*:
Zip Code*:
Day Phone:
E-mail Address*:
STEP 2: ORDER INFORMATION
Number of Bottles*:	(if you’d like 6 bottles, you will automatically receive a 7th for FREE!)
STEP 3: PAYMENT INFORMATION Payable to Eye Associates
Type of Credit Card*:
Credit Card Number*:
Expiration Date*: ( i.e. 02/2008)	/ (Month/Year)
FEEDBACK Quick survey to help us better our availability online (optional).
How did you hear about us?:
If you found us by Search Engine, what search words did you type to find us?:		( i.e. eye supplement)
*Required Field Orders only shipped to the USA and 9.25% sales tax is collected on all orders.
Helpful Ordering Information: Tab through each field then click Print Form above. To fax, click Print Form above and Fax: 707.823.1521 To mail, click Print Form above and Mail: Horizon Complete `c/o` Eye Associates 6880 Palm Avenue P.O. Box 1777 Sebastopol, CA 95472 (Click Reset Form button to correct any information.)