Order Form

To place your order for, simply fill in this form and fax or post it to:

Radical Health Care
29 Clive Road
Canton
Cardiff
CF5 1HF

Fax: UK 0870 132 7011

Product Name	Unit Price	Quantity	Total
Instant Ice Pack	£37.00
Hot/Cold Compress inc. pouch	£12.99
Hot/Cold Compress without pouch	£8.49
Hand Warmer	£6.99

Shipping

UK mainland	Europe	Other countries	Total
Free	N/A	N/A	Nil

Grand Total

Your Details

Your name:	Organisation:
Delivery address:	Invoice Address (if different):
Telephone:	Fax:
Email:	Web:

Payment details
Unless agreed beforehand we require payment with your order.

Payment for your order must be made at the time of order. If you require a pro-forma invoice to raise payment, choose the invoice option below and we will ship when payment is made.

[__] Credit card.
For fastest shipping, use credit card payment. You may prefer to fax credit card details.

My card:

[__] MasterCard. [__] VISA. .

Card Number: ______________________________

Expiry: ___________

Security code : _______________ (last 3 digits printed on signature strip)

Signature:

[__] Cheque payment.
I enclose my cheque payable to Radical Healthcare: £

[__] Direct Transfer Payment.
We have arranged for a direct transfer to your bank (email us for detail). Reference: