Herbal Doctor Remedies Order Form

Email address:
Your Name:
Shipping and
billing address:
State: Zip:
Item Qty. Unit Price Qty. times Price
Order Total

Shipping Address ( if different):

City StateZip

Payment Method

Card Type:
Card No:
Expiration Date (mm/dd):/Validation Code (3-4 digit number)
Name Appearing on Card:
Daytime Phone number:
Evening phone number:
I agree to pay above total amount according to card issuer agreement

Signature ___________________________________

Check or Money Order Enclosed Make check or money order

payable to Herbal Doctor Remedies

2434 W Main St Ste 202, Alhambra CA 91801-7018 USA