Send this form in with a check or
credit card information to:

    The Memory Doc
    PO Box 741763
    Boynton Beach, FL 33474

CALL: 561-200-9380 to order! 

           SHIPPING ADDRESS:

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CIRCLE: (VISA/MC/AM EXPRESS)

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  Quantity                          Total

___BOOK(s) w/ 2 bonus CD's @ $10.00   $________

  
___E-Book(s) @ $3.00   $________

  
___2 Audio CD PROGRAM @ $3.00    $________ 

  
___Wheat Grass @ $22.00             $________

___ Phosphatidylserine (PS) & Phosphatidylcholine (PC)

       2 bottle combo--(NOW/Countrylife) $53 $________

___   Phosphatidylserine (PS) single 100 gel caps 100 mg $41  $ ______

___   Phosphatidylcholine (PC) single 100 gel caps 1200 mg $16  $______ 

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SHIPPING/HANDLING 

USA Shipping -- Please add:
                        $4 -  EACH 1ST PRODUCT              $ _________
                           $2  - EACH ADDITIONAL PRODUCT  $ _______
                                

                                            SHIPPING SUBTOTAL    $ _______

		                       PRODUCT SUBTOTAL       $_______

                                                                TOTAL          $_______