Lose the Back Pain System - Print Order Form

Lose the Back Pain - No Risk Order Form

YES! I'm ready to use the Lose the Back Pain System to identify and address my imbalances and wipe out my pain.

I understand that I can try the system risk-free for one full month and if I don't start feeling a decrease in my pain and feeling better, I can send the system back for a complete refund (minus shipping).

I'll pay just $97 plus $8 shipping and handling. $15 if ordering from outside the US.

For Fastest Service:

Fax your credit card order to (866) 843-4319

Or mail with payment to the address below:

The Healthy Back Institute

13507 Pulaski Drive

Hagerstown, MD 21742 USA

Choose Your Format:

( ) DVD ( ) VHS (US & Canada only)

Method of Payment:

( ) Check / Money Order (Must be in US Funds. Make checks payable to: The Healthy Back Institute)

( ) VISA ( ) MasterCard ( ) American Express ( ) Discover

Credit Card # __________________________________ Exp. Date _____/_____

Signature _________________________________________________________

Customer Information:

Name: _____________________________ Email: _______________________________

Phone: _____________________________

Billing Address:

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Address: ________________________________

City: ___________________________________

State: _________ Zip/Post Code: _________

Country: ________________________________

Shipping Address ( if same leave blank):

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Address: ________________________________

City: ___________________________________

State: _________ Zip/Post Code: _________

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