ORDER ENTRY FORM: 

ELITE #30 VITAMINS Moisturizer/ Eye Serum    containing Bio-Identical Hormones

Edward Lichten, M.D.,PC
189 Townsend St 2nd floor
Birmingham, MI 48009 
248.593.9999

 Print Order Entry Form

Ship To: Name: ___________________________________

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Shipping: United States Postal Service:  3 day ground   to U. S. included

Bill To: Name: ____________________________________

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ELITE VITAMIN BOX 30 packs $99.99/       QUANTITY [    ]  TOTAL=  $______

MOISTURIZER & EYE SERUM $99.99/       QUANTITY [    ]  TOTAL = $______

FAX TO:  248.593.9037    
MAIL TO:
Edward Lichten MD PC, 189 Townsend Street  Birmingham, MI 48009