120 East 56th Street, 12th Floor New York, NY 10022 TEL: 212-973-9425 FAX: 212-973-1029
RETAIL ORDER FORM ( print out form and fax order to company )	HOME

Order By:_____________________________________	Shipped to:___________________________________
Name: ______________________________________	Name: ______________________________________
Practice Name: _______________________________	Practice Name: _______________________________
Address: ____________________________________	Address: ____________________________________
City: _________________State: _____ Zip: _________	City: _________________State: _____ Zip: _________
Phone:______________________________________	Phone:______________________________________

PLEASE NOTE: Contact Company for wholesale prices and minimum order amount of each Item listed below.

Description	Qty.-Plain	Qty.-Menthol	Unit Price	TOTAL
Dental Powder			21.00
Oral Rinse			26.00
Herbal Capsules			36.00
Dental Powder			21.00
Oral Rinse			26.00
Herbal Capsules			36.00
Dental Powder			21.00
Oral Rinse			26.00
Herbal Capsules			36.00

PAYMENT METHOD Check Make payable to: THE HERBAL DIFFERENCE, Inc.     VISA     MasterCard      AMEX      DISCOVER CARD NO: _____________________________________ EXP. DATE: _____________________________________ SIGNATURE: ____________________________________ PRINT NAME: ___________________________________ Of cardholder exactly as on card

Sub Total   Shipping & Handling 7% of product subtotal   Tax 8.625% ( If applicable )   GRAND TOTAL   FOR SHIPPING OUTSIDE CONTINENTAL U.S. OR 2ND DAY DELIVERY, CALL FOR PRICING

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120 East 56th Street, 12th Floor New York, NY 10022 TEL: 212-973-9425 FAX: 212-973-1029