Cardholder Name
Telephone
Email Address
I authorize a charge of
on my	MasterCard    Visa   Amex Credit Card (choose one)
Card Number
CVV Code
CVV is an anti-fraud security feature to help verify that you are in possession of your credit card.
	For American Express, the four-digit CVV number is printed on the front of the card above the card accountnumber.
	For Visa/Mastercard, the three-digit CVV number is printed on the signature panel on the back of the card immediately after the card's account number.
Expiration Date	(month XX) (day XX) (year XXXX)
ITEM(s) Ordered: Angel of Water® Complete Packaged Unit (comes complete with ever thing you need to start doing colonics including a sanitation kit that contains the disinfectants, sanitizers, and tools needed to perform your pre- and post-session protocols.) $11,999.00 plus approx $500 Continental US Delivery = $12,499.00 DELIVERED Monthly Consumables Extra Shipping:   $1300 Hawaii / Europe/ South America NEED PRESCRIPTION TO ORDER   Description: Billing Address For Credit Card (this must match credit card statement) (company) (street) (city) (state) (zip)
Signature: _____________________________________________________________

  SAME AS BILL TO ADDRESS

Ship to Address
(company)

(street)

(city) (state)

(zip)