Date: __________ For Office Use: __________________ No. ____________

Last Name: ________________________ First _________________ MI ____

Spouse’s Name: ___________________________________________________

Local address: ______________________________City: __________________

State: _______ Zipcode: __________________

Daytime Phone: __________________ Evening Phone: ___________________

Fax No. _____________________ E-mail address :_______________________

Other Phone numbers: _________________ _________________________

Physician Name: __________________________________________________

Credit Card Type: ____________ Number _____________________________

Exp. Date: ___________

I wish to have automatic shipment at the following frequency:

Please ship: A month’s supply -- each month: _____

Three months supply ____ (10% discount + free shipping & handling)

Six months supply ____ (15% discount + free shipping & handling)

Twelve months supply ____ (20% discount + free shipping & handling)

For product:

____ Cardio-Pak

____ Cardio-Pak Plus

____ Cardio-Pak Plus Fiber

Mailing Address: _____________________________City: ________________

State: __________ Zip: _____________

I understand that nutritional supplements and wellness consulting are

services generally not reimbursable by Insurance Companies, yet!

Signature _____________________________ Date _____________

Please FAX to Genesis Center, Inc. 24-hours: 256-442-4820