Order form for: Lipoprint^® - A Breakthrough in Cholesterol Management. Price: $24.95

For fax orders, please print, fill out and fax to: 800.845.1834

For postal orders, please print, fill out and mail to:

Quantimetrix Corporation, Dr. Robert W. Ban
2005 Manhattan Beach Boulevard, Redondo Beach
CA 90278, USA

---

Name ____________________________________________________________

Address __________________________________________________________

City _______________________________ State ______ Zip ________________

Telephone ________________________________________________________

Email ____________________________________________________________

Sales tax: Please add 8.5% for products shipped to California addresses

Shipping Cost by air: U.S. $8.00 for first book and $4.00 for each additional book. International $9.00 for first book; $5.00 for each additional book (estimate).

Payment: __ Check   __ Credit Card (please check type): __ Visa   __MasterCard

Card Number ____________________________________ Exp. Date _________

Name on Card _____________________________________________________

Signature _________________________________________________________

Once the order is received, we will contact you to confirm the order. If you have any questions, please email: monica@4qc or call 310.536.0006 Thank You for your order!