beCalm’d For ADD/ADHD FREE KIDS | Prices

Neuro Health Products Order Form
Retail Sales Only With This Form.

Print and Fax this document to 281-332-4753 . . .or mail it to:
NeuroGenesis, Inc.
120 Park Avenue
League City Tx. 77573-2446

Distributor: HMG Marketing – ID# 6308AJ

Make Checks and Money Orders Payable To: NeuroGenesis, Inc.

Full Name:_____________________________________________________
Street address :_________________________________________________
______________________________________________________________
Phone:____________________ Fax: ____________________________
E-mail:_________________________
Becalmd Order: Retail: Quantity:
beCALM’d -90 Cap $37.50 ______
beCALM’d 90 Cap (4 Pack $36.00 per bottle) $146.00 ______
beCALM’d Chewable -90 Tabs $35.50 ______
* Include shipping and handling. S & H ______
Total: ______

Shipping and Handling

1-4 Bottles $6.30
5-8 Bottles $7.90
9-12 Bottles $10.75
Over 12 bottles or outside of USA shipping prices will vary.

All prices are in US dollars.

Card Type:___________________________________
Card Number:________________________________
Expiration Date:___________
Name on Card:__________________________________
Message:________________________________________________________
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