Personal Health Lifestyles Order Form

Ordering Information

Here are four alternatives you can use to submit your order to us.

Complete this form and submit it to us. All information is kept confidential and protected
through a secure socket connection

Call us toll free at 1-800-943-1123

Print out this page and fax it to us at 1-801-224-4787

Print out this page and send it to us at

Shipping Address

Please enter the address where your order is to be delivered.

First Name:
Last Name:
Address:

City:       State/Province:
Zip:       Email:
Daytime Phone:       Evening Phone:
Country:

NOTE: Please be sure to enter a phone number where you can be contacted if there are questions or discounts relating to your purchase, and the email address where your order confirmation is to be sent.

Billing Address

Please enter the address registered with your Credit Card Company.

Check here if the billing address is the same as the shipping address.

Name:
Address:

City:        State/Province:
Zip:        Phone:
Country:

Further Shipping and Billing Information

Wholesale Buyer
Number:
This is only informational for tracking referrals and is not required to order or to get wholesale pricing. ALL orders are automatically processed using wholesale prices.
All shipments are sent via UPS Ground service. MINIMUM SHIPPING CHARGE IS $7. Usually, your delivery will take 5 to 7 business days (Express delivery options are available through phone orders).

Save shipping and billing information for future orders.

Payment Method

Type of Bank Card:


Card Number:

Expiration Date:    Month   Year

Products Ordered

Please verify that your order is correct.

NOTE: The above subtotal does not include shipping fees and sales tax. A shipping and processing fee of 10% will be added to each order (Minimum Shipping Fee is set at $7.00), and Utah State Sales Tax of 6.5% will be added to all orders shipped within the State of Utah.