Fax order form

To order any of our home test kits by fax, please print out this form, complete in black ink, sign and fax to our offices.

Our fax number is +27.12.361 0061

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FAX ORDER FORM
Surname 
Name  
Postal address  
   
   
   
Zip code  
Country  
Telephone number (Country code + area + number)
e-mail address (used to confirm dispatch)
Items required Item name Quantity Price 
(US Dollars)		 Total
         
         
         
         
         
    TOTAL TO BE BILLED  
Credit card details 
Credit card type (Specify Visa, MasterCard, Amex or Diners)
Card number                                
Expiry date Month then year    
CCV number Visa and MasterCard cards >          Amex cards >            
Your signature  
   
Special instructions and notes