ICQ #:
Any Medical Problems
YES
NO
If you answered YES then explain what medical problems:
I WOULD LIKE TO LOSE:(select one)
Please tell me a little about yourself!
Do you have a friend or loved one that
needs to get healthy?
Send them this page by putting their email
in the box below.
When you hit the send button, a browser box will pop up telling
you a warning. This is just letting you know that your
are sending a form to me with your email address on it
.
Click
and then click send.
Your information will be kept confidental, and your samples will
be mailed to you in 8 to 10 days
Thank you for your time and hit the send button when every
question is filled out!
Also it has come to my attention that about 20% of request
are not making it back to me due to
and error in my mail server and this form.
As a extra step, please also send me a blank email to let me know your
requesting these samples.
I want to make sure your getting through to me!
Click on my name below to send the blank email! Thanks!
Email: Brian Shanks