Made in U.S.A.

Gel Therapy Consumer Order Form

For your protection , we will not ask for your credit card information over the Internet.

After you fill out and "Send" the order form below, we will call you back to confirm your order, verify your shipping address, and arrange for payment. We want you to feel safe shopping at our web site!

Simply enter a number of packages next to each product you want to order (you do not have to enter a 0 if you do not want a product). When you're done, click "Send Order" to send your order to us.

Prices for consumers
(minimum 2 packages plus freight/handling)
(Color will be either: blue, green or pink – Specify if you have a preference)

Newport Products
Qty	Product / SKU	Prices (EA / 2 PACK)	HDL/FGT	TOTAL / 2 PACK
	Eye Mask-Assorted N-103	$6.00 12.00	$8.00	$20.00
	Eye Lids-Assorted N-203	$5.00 $10.00	$8.00	$18.00
	Relief 'Rap-Assorted N-303	$7.00 $14.00	$8.00	$22.00
	Sports 'Rap-Sky Blue N-400	$7.00 $14.00	$8.00	$22.00
	Full Face Mask-Assorted N-503	$20.00 $40.00	$10.00	56.00
Botanical Rex Products
Qty	Product / SKU	Prices (EA / 2 PACK)	HDL/FGT	TOTAL / 2 PACK
	Eye Mask- Earth Green BR-100	$7.50 $15.00	$8.00	$23.00
	Eye Lids- Earth Green BR-200	$7.00 $14.00	$8.00	$22.00
Name:
Company:
Address1:
Address2:
City:
State:
Zip Code:
E-mail: (Important to include so we can contact you!)
Telephone: (Important to include so we can contact you!)
Comments / Special Instructions:

THANK YOU FOR YOUR ORDER!

If you have any challenges with this order form, please feel free to call:

Toll Free: 888-863-5677 (888-To-Floss)
Toll Free: 800-735-3504

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