Purchaser Information |
| Name |
| Addresss |
| City |
| Country Post Code |
| Phone | Fax |
| Todays Date |
Payment Details Visa [ ] M/ C [ ] Cheque [ ] Direct Credit [ ] |
| Expiry Date Name on Card |
Card Number |
Direct Payment BNZ Upper Riccarton Vivace Health 020820 : 0003602 : 00 Make Cheques to Vivace Health Thankyou. |
| Please Post to 88a Browns Road Merivale Christchurch 8014 New Zealand Fax 64 03 3552764 Phone 64 03 3552766 |
Product | Price | Total |
| Serenity Progesterone Cream | $70.00 | |
| Serenity Triest Cream | $70.00 | |
| Levity B Complex | $25.00 | |
| The Body Blues Book Special Price | $20.00 | |
| Serenity Products Include Priority Mail from Florida | ||
| Levity Products Include Postage within New Zealand | ||
| Total Cost in New Zealand Dollars |
