Order Form

coupon code (enter exactly as shown)

Billing and Payment Information:

Please fill in your payment information below. Items marked with an asterix (*) are required.

** If your billing information is an APO address or a P.O Box Address, then you must contact us at info@jeevanhealth.com- our system may not accept your order. Alternately, you can add your information and Pay via Paypal. Remember, your billing address must be the address where your credit card statement arrives.

First Name: ^*

Last Name: ^*

Address: ^*

City: ^*

State: ^*

Postal Code: ^*

Country: ^*

E-Mail:

Day Phone:

Payment Method:


Master Card


Visa


American Express

Number

CVV(II) Number
What is this?

Expiration Date


PayPal
** please note that under paypal, the business name arc4life will come up. This is the parent business through which all paypal accounting is completed.

Enter the security code shown below *:

Security Code:

* For security purposes, we ask that you enter the security code that is shown in the yellow / black graphic. Please enter the code exactly as it is shown in the graphic.

Shipping Information

Please fill in your shipping information below. Items marked with an asterix (*) are required.

Same as Billing Information

First Name: ^*

Last Name: ^*

Address: ^*

City: ^*

State: ^*

Postal Code: ^*

Country: ^*

E-Mail:

Day Phone:

Additional Information / Comments:

** Please note that your credit card statement will read "CT Spine and Disc Center LLC" This is the parent business through which all credit card processing is completed. Thank you.

Email Address: (please provide this so that we may send you a Shipping Confirmation)

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Order Form

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