ColonHealth On-Line Order Form

ColonHealth Order Form

A Public Service Site from Esteem & Associates, Inc.

There are 4 ways to place an order!

1.Fill in, print out and MAIL this form, along with your payment, to the address below:

Esteem & Associates
269 S. Beverly Drive
# 321
Beverly Hills, CA 90212

2.PHONE your order by calling our phone number - 24 hours a day!

Phone: 310-572-9094

3.Fill in, print out and FAX this form to the number below:

Fax: 814-286-1245

4.SUBMIT your order online! Just fill out the form, then click the "Send My Order" button below!

My Address:

Name:   
 
Address:
 
City:   

State:    Zip: 

Ctry:   
  
Phone:  
 
Email:

Product Information

  Qty     Item# Description                     Price

1.
2.
3.
4.
5.
6.
7.
8.

             SUBTOTAL :                       
 
             Add shipping charges (See Below):

             Insurance  :                     $3.00
 
             Sales Tax 8.25% (Calif. res. only):

             Total Payment:

Shipping Charges

 
 Up to  $ 25.00- $ 5.95
$ 25.01-$ 50.00- $ 7.95
$ 50.01-$100.00- $ 8.95
$100.01-$200.00- $ 9.95
$200.01-$300.00- $10.95
$300.01-$500.00- $14.95
Canada Add     - $ 5.00 EXTRA 
All other Foreign ...triple postage

PLEASE ALLOW UP TO 2 - 4 WEEKS FOR DELIVERY ON MOST ITEMS.
WE USE POST OFFICE OR UPS.....NO NEXT DAY DELIVERY!!

Payment Method:

Visa  
MasterCard

Note: If you prefer to make payment via Check or Money Order, please print this order form and mail it with your payment to the address above.

Account Number:
Expiration Date :

Signature: ___________________________________
***Name as it appears on your card*** (Note: This line needs to be signed when you are sending or faxing your order.)
Comments:
NOTE: Please be sure to include your phone number so we can contact you if there are questions. Thank you.