MeltRx.com Order Form

Print, Fax or Mail In Your MeltRx 24 Ultra® Order
Fax to: 1-800-957-1527 Or, Mail it to:
SHC C/O MeltRx.com
8437 Tuttle Ave. #403
Sarasota, FL 34243

Name: _________________________ City: _________________________
Email: _________________________ State: _________________________
Address: _________________________ Country: _________________________
Phone: (____) ______ - ____________ Zip: _________________________
MeltRx® — 1 Bottle _____ @ $54.00 = $ __________
MeltRx® — 2 Bottles Get 1 FREE _____ @ $108.00 = $ __________
MeltRx® — 3 Bottles Get 2 FREE _____ @ $162.00 = $ __________
MeltRx® — 5 Bottles Get 4 FREE _____ @ $270.00 = $ __________
SUB TOTAL = $ __________
Shipping & Handling = $ __________
TOTAL = $ __________

Standard Domestic Shipping: Free; Upgrade to UPS 2-Day Delivery for only $19.95 (not available to APO, FPO, or PO Boxes) US ONLY; Upgrade to UPS Next-Day Delivery for $39.95 (not available to APO, FPO, or PO Boxes) US ONLY; Hawaii, Alaska, Puerto Rico, US Virgin Isles, Guam: $12.95; All other countries: $19.95

(  ) I am enclosing a check or money order for $____________
Please note: If you are paying by check you must make it payable to SHC, LLC
and mail it in. We do not accept checks by fax.

(  ) I want to charge this purchase to my Credit Card

Credit Card (check one):

VISA       MasterCard      American Express      Discover

Card Number: _________________________

Expiration Date: _________        Signature: _________________________

I authorize SHC, LLC to charge $____________ to my credit card for the purchase (and shipment) of the above products.

Note: If you are using a credit card charges will show up on your statement under SHC, LLC which is our parent company. All orders will be shipped within 48 hours of receipt. Orders accompanied by checks will be held until cleared.