The Rebuild Your Vision Ocu-Plus
Order Form
Click here to print this order form

Print this form and fax or send your shipping and payment information to:

      Mail:   Rebuild Your Vision                      OR                   Fax: (877) 634-7547
                 14241 NE Woodinville-Duvall Road, #398
                 Woodinville, WA 98072


First Name:
____________________________________________
Last Name:
 ____________________________________________
Shipping Address:
 ____________________________________________
____________________________________________
City:
 __________________ State: _____ ZIP: _________
Telephone:
 __________________
E-mail:
 ____________________________________________
   
MONTHLY DELIVERY
____ $37 special price (35% Discount + FREE POSTAGE)

This offer is valid for credit card orders only. I understand by choosing monthly delivery I will be sent one bottle every month until I cancel.
 

BUY 3 BOTTLES
GET 1 FREE

 ____ $171 special price (25% Discount)
$57 per bottle + $14.95 postage = $185.95 total
 
INDIVIDUAL
OCU-PLUS FORMULA
____ $47 special price (17% Discount)
$47 per bottle + $3.95 Postage = $50.95 total
   
Method of Payment:
 Visa _____ MasterCard _____ Discover _____
AmEx _____ Check_____ Money Order _____
Make checks and money orders payable to:
Rebuild Your Vision, LLC
   
Credit Card Number: ____________________________________________
Expiration Date: _____________
Name on Card: ____________________________________________
   
Billing Address: ____________________________________________
(if different than above) ____________________________________________
City: __________________ State: _____ ZIP: ________
   

If you have questions or would like more information about the
Rebuild Your Vision Ocu-Plus Formula, please call us toll-free at (877) SEE-4LIFE.