South African 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 012.361 0061.

Click here to return to the home page, or here for our South African product catalogue, or use the "back" button of your browser to go back to the previous page.

PLEASE NOTE – We charge R 30.00 for delivery anywhere in South Africa and our minimum order quantity is R 150.00 per order.

FAX ORDER FORM
Surname 
Name  
Physical address  
   
   
   
Postal code  
Country  South Africa
Telephone number (Area + number)
e-mail address (used to confirm dispatch)
Items required Item name Quantity Price 
(ZA Rand)		 Total
         
         
         
         
         
Courier charges   R 30.00
    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