• 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

• Questions Email whyteachhealth@gmail.com

First Name:     Last Name:     Address:     City:        State/Province:   AL AlabamaAK Alaska AS American SamoaAZ Arizona AR ArkansasCA California CO ColoradoCT Connecticut DE DelawareDC District of Columbia FL FloridaGA Georgia GU GuamHI Hawaii ID IdahoIL Illinois IN IndianaIA Iowa KS KansasKY Kentucky LA LouisianaME Maine MD MarylandMA Massachusetts MI MichiganMN Minnesota MS MississippiMO Missouri MT MontanaNE Nebraska NV NevadaNH New Hampshire NJ New JerseyNM New Mexico NY New YorkNC North Carolina ND North DakotaOH Ohio OK OklahomaOR Oregon PA PennsylvaniaPR Puerto Rico RI Rhode IslandSC South Carolina SD South DakotaTN Tennessee TX TexasUT Utah VT VermontVI Virgin Islands VA VirginiaWA Washington WV West VirginiaWI Wisconsin WY Wyoming Zip:        Email:  Daytime Phone:        Evening Phone:   Country:     US United StatesVI Virgin Islands (U.S.)

 
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:    AL AlabamaAK Alaska AS American SamoaAZ Arizona AR ArkansasCA California CO ColoradoCT Connecticut DE DelawareDC District of Columbia FL FloridaGA Georgia GU GuamHI Hawaii ID IdahoIL Illinois IN IndianaIA Iowa KS KansasKY Kentucky LA LouisianaME Maine MD MarylandMA Massachusetts MI MichiganMN Minnesota MS MississippiMO Missouri MT MontanaNE Nebraska NV NevadaNH New Hampshire NJ New JerseyNM New Mexico NY New YorkNC North Carolina ND North DakotaOH Ohio OK OklahomaOR Oregon PA PennsylvaniaPR Puerto Rico RI Rhode IslandSC South Carolina SD South DakotaTN Tennessee TX TexasUT Utah VT VermontVI Virgin Islands VA VirginiaWA Washington WV West VirginiaWI Wisconsin WY Wyoming Zip:         Phone:  Country:     US United StatesVI Virgin Islands (U.S.)

 

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 or US Postal service. MINIMUM SHIPPING CHARGE IS $8 or (10%). 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:     American ExpressDiscoverMasterCardVisa        Card Number:     Expiration Date:     Month JanFebMar AprMayJun JulAugSep OctNovDec   Year 20232024 202520262027202820292030

 

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 $10.00). Shipping and processing fees for out side the continental United States is 20% and a minimum of $16.00. Utah State Sales Tax of 6.5% will be added to all orders shipped within the State of Utah.