| Description | Qty. | Price | Total | |||
| Coenzyme Q10 | $29.95 | $ | ||||
| DHEA | $12.95 | $ | ||||
| Double G SuperPower | $15.95 | $ | ||||
| Echinacea | $8.95 | $ | ||||
| Ginkgo Biloba | $12.95 | $ | ||||
| Golden Ener-Z | $12.95 | $ | ||||
| Good Dream | $19.95 | $ | ||||
| HairMillion | $89.95 | $ | ||||
| HemoStream | $39.95 | $ | ||||
| Herbal Breath | $19.95 | $ | ||||
| LaxaColon | $24.95 | $ | ||||
| Lutein-20 | $16.95 | $ | ||||
| Lutein-6 | $12.95 | $ | ||||
| Milk Thistle Healthy Liver | $16.95 | $ | ||||
| PeptiTonic | $24.95 | $ | ||||
| Royal Jelly | $12.95 | $ | ||||
| Saw Palmetto | $15.95 | $ | ||||
| Slim Essence | $29.95 | $ | ||||
| Stomagic | $29.95 | $ | ||||
| Triple B SuperVision | $19.95 | $ | ||||
| Triple G SuperHealth | $15.95 | $ | ||||
| Sub Total | $ | |||||
| Sales Tax (Within California Only) 8.25% | $ | |||||
| Shipping & Handling (2-3 days) $4.00 flat fee. | $ 4.00 | |||||
| International shipping | $ | Click to find rate. | ||||
| Order Total | $ | |||||
| Mail this form with a check payment to: | ||||||
| DreamPharm | ||||||
| P.O. Box 9470 | ||||||
| Glendale, CA 91226-9470 | ||||||
| For credit card orders fax to: | ||||||
| (818) 583-1744 | ||||||
| Name: _____________________________ | ||||||
| Address: ___________________________ | ||||||
| ____________________________ | ||||||
| Phone No.: __________________________ | ||||||
| __Visa __M/C __ Disc __Amex | ||||||
| No. __________________________ | ||||||
| Exp. ____/____ | ||||||
| 3 digit code on the back of the credit card ________ | ||||||
| For more products, information,and to place an order online, | ||||||
| please visit our website at www.dreampharm.com. | ||||||