Diets to Your Door

To simply contact us, just fill out your name, email and comments fields and hit submit. To place an order, either print this form out and fax or mail it to us with payment information, or submit this form online and we will contact you for your payment information.

Phone: 847-432-6550 or Fax Order Forms to 847-432-5945

Name:

Address:

Home Phone:

Cell:

Work:

Fax:

Email:

Start Date:

Check your plan:

Full $28.95/Day
Partial $23.95/Day
Trial $31.95/Day

Total Days:

x Cost/Day:

=Total:

(For Printout Only) Check Enclosed:

(For Printout Only)
Credit Card Number:

_____________________

Type of Card:

_____________________

Expiration Date:

_____________________

Questions or Comments:

* Please allow 24 hours for delivery to begin.
*$100.00 Cancellation Fee

+Prices Subject to Change + Contact your Dr. before starting any weight loss program