The Rebuild Your Vision Program
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:
 ____________________________________________
 
Number of Kits:
 ____ kit(s) $97 special price  
U.S. Orders: $111.95 per kit ($97 + $14.95 Postage)
Canada Orders: $116.95 per kit ($97 + $19.95 Postage)
International Orders: $121.95 per kit ($97 + $24.95 Postage)
   
Ocu-Plus Formula:
____ Bottle(s) $27 special price
  U.S. and Canada Orders: $30.95 per bottle ($27 + $3.95 Postage)
International Orders: $35.95 per bottle ($27 + $8.95 Postage)
Credit Card Orders Only: ___ Please send me one bottle at the special price every month until I cancel
   
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 Program, please call us toll-free at (877) SEE-4LIFE.

www.rebuildyourvision.com