AQUA-CEL Logo


Introductory Offer
Each Size:$17.50
Both Sizes:$30.00
Yes, I would like to try the AQUA-RELIEF(tm) Pad at the Special Introductory Price.

ORDER FORM

First Name:

 Last Name
Day Phone

 E-mail address:
Shipping Address (No P.O. Boxes):
 City
State:
 Country:
Zip Code:
Payment Type:
Visa Mastercard		 Credit Card Number:
Expiration Date & CCV Number
 Cardholder's Name
Signature (For Fax or Mail Order ONLY)
_____________________________________________
Items:
Back Pad ($17.50) Cervical Pad ($17.50) Both ($30.00)
Shipping (Please allow 1-2 weeks U.S. and 2-3 weeks other):
U.S. $7 each $9 both
Canada (UPS) $15 each $16 both
Europe (Parcel Post) $20 each $25 both (U.S. funds only)		 Total: Includes Shipping
Make sure you have filled in something for every field.


Options: Mail or Fax Order NO ON-LINE ORDERING
Print out Order Form and mail or fax to the number below or call the Toll Free number (U.S. Only)


Order Form Distributors

AQUA-CEL Corporation
P.O. Box 26827
Santa Ana, CA 92799
(888) 254-HEAT (4328) (U.S. Only)
Phone/Fax (714) 962-2776
aqua-cel@aqua-cel.com