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Printer Form for Mail Order (Go to "File" and "Print") or Order Online
Please print clearly. Fields marked with an asterisk (*) are required to process this order.
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Customer Name:
Address:
City: State: Zip:
Day Phone: Eve. Phone: Fax: E-mail:
Qty Item Description Price Total
  HEVF4 Hair Energizer™ Best Value 4 month supply (4 bottles Vitamins, 2 bottles Follicle Stimulator)

$64.95

  
HEVH2 Hair Energizer™ Best Value 2 month  (2 bottles Vitamins, 1 bottles Follicle Stimulator) $34.95
HEVF1 Hair Energizer™ "Try Me"  w/o shampoo (1 bottles vitamins, 8 oz Follicle stimulator) $29.99
  HFVCP 1 Month Trial Kit w/ Emu Shampoo 8 oz, HE vitamin (60), HE Follicle stim (4 oz)  $35.95  
  HFVC 2 Month starter kit (double what is on the line above) $64.95  
  HEV Hair Energizer™ Vitamins (2 bottles - 60 tablets per bottle) (2 month) $22.95  
  HEFS Hair Energizer™ Follicle Stimulator (8 oz  per bottle)  (2 month) $18.95  
  HES Hair Energizer™ EMU Energizing shampoo (16 oz   bottle) ( 2 Month) $12.95  
  HEV4 Hair Energizer™ Vitamins ( 4 bottles - 60 tablets per bottle) (4 month) $36.95  
  HFT Dry Hair Kit w/ Emu Shampoo and Silk Protein Conditioner and 1/2 jojoba oil $22.95  
  HE-4 4 month Hair Energizer Plan 4 bottles of hair energizer vitamins, 2 bottles of Follicle stimulator and 2 bottles of Emu shampoo 

     

     

 $79.95  
  HE-6 6 Month - Hair Energizer Plan ™ 
    Same as above with an an extra bottle of each!

     

 
 $109.95  
SUBTOTAL:  
SALES TAX:
(8.25% in TN)		  
SHIPPING (USA ONLY): $4.00
TOTAL AMOUNT: $
PAYMENT INFORMATION
PAYMENT TYPE:* (Please select one.) No Cash or C.O.D. accepted. Check/money order payments accepted with postal mail orders ONLY.
  Credit Card   Check**   Money Order
** Make checks payable to: Hair Energizer (checks must be in US dollars ONLY)

CREDIT CARD PAYMENT INFORMATION:
TYPE OF CARD:*
  Visa   MasterCard   American Express
CARD NUMBER:* (Must be 16 digits) EXP. DATE*
    |    |    |    |    |    |    |    |    |    |    |    |    |    |    |    |
CARDHOLDER'S NAME AS IT APPEARS ON THE CARD:*
 
CARDHOLDER'S SIGNATURE:* (Orders can not be processed without signature)
X

Mail your order / check payable  to:

Hair Energizer
PO Box 901
Grayson, GA 30017

888-909-1658 
(toll free ordering ~ 8-4 Eastern Time ~ Mon.-Fri.)

 

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