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Alternative Health On Line - Order Form
 

There are two ways to order electronically from Alternative Health Centre

1. Online Website Internet Order		2. FAX order form
To complete your online order, just Fill in this form and fax - or phone your details. Email Orders		If you would prefer to FAX an order Please print out this sheet and fax to:- +61. 07.    3805 6422

You are Ordering:
	Alka-Water Ionic Alkaline Water for vital health. Cost $AU $15-00		How many Bottles of Alka-Water do you require We will call you if we cannot deliver your request.
	Select Price: (incl. GST)				____ at 15-00	TOTAL UP YOUR ORDER Amount: $
Include Postage to pay AU$ 10 per 1-3 Ltrs $20 per 4-6 ltrs AU$30 per 7-10 ltrs EMAILl			How do you wish to pay - (tick) VISA  MASTER Credit Card     Cheq

Delivery - Details of DELIVERY:

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	Name of Recipient:
	Name of Business, SHOP, WHOLESALER, etc:
	Level in hi-rise (if known):
	Street Address: (include Unit number where applicable)	Private Address?
	Suburb/Town/City:
	Phone:	Landline: Mobile:
	Optional: If you give us some details on your general health and any problems you have we will send you some important information and tips on full recovery for you to consider -These newsletters are free of charge	25 words or less, please!

Your Details Please:
(We need to know how to contact you to verify order or check details.)

	Your Name:
	Street Address:
	Suburb/Town/City:
	State/Province:
	Country (if other than Australia):
	Phone:	Landline: Mobile:
	Your E-mail Address:
	How did you find our Website?:	Please select... Search Engine Previous Order

Optional - Your Credit Card Details Please:
(see note ** below)

	Cardholder's Name: (as printed on card)
	Type of Card:	Select... Bankcard VISA MasterCard Diners Club American Express Expiry Date (mm/yy):
	Card number:		ID number:

Thank you for your order enquiry. Please click to send:

If you want to clear the form and start again, click:

** (We will treat your card details with confidence. However, if you are more comfortable sending your order by FAX or phone, please click here (Fax), or phone our friendly staff during business hours on (+61. 7) 3200 4100 Or please  Email now

Remember, if you prefer to discuss your special requirements with one of our staff, please phone our Central Ordering Hotline +61. 7. 3200 4100- Mobile 0411 855890 OR     EMAIL

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