Product Order Form Order Form *Info Required Order Form 1/1/2021 Doctor or Practice Name*Shipping Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country International orders are subject to additional shipping costs, you will be contacted by a representative via email shortly.Email Address* Office Phone*FAXPatient EducationSelect the quantity of the item(s) you'd like to order.Wellness Education Club Monthly Subscription Annual Subscription The Wellness Family Newsletter 1 Year Subscription Past Issues Chiropractic Feet, Gait and Chiropractic What Controls You? Fertility and Chiropractic Balance and Chiropractic Tech Neck Posture Matters What is a Family Wellness Chiropractor? Women and Pregnancy The Webster Technique Pre-Conception Wellness Breastfeeding Pelvic Floor Babies Tummy Time and Crawling First Adjustment Teething Symptoms and Home Remedies Otitis Media Tethered Oral Tissues or Tongue Tie Baby Wearing Children Antibiotic Misuse Home Remedies Healthy Poops Food and Nutrition Why am I confused about Salt? Camouflaged Sugar Garlic, Onions and More Fermented Foods Honey and Bees Focused Wellness Reclaiming Your 20 Mindfulness The Power of Breathing For more information regarding these available titles please click here.The Did You Know Series 1 Year Subscription All subscriptions are automatically renewed annually, unless requested otherwise.This field is hidden when viewing the formPatient Education Subtotal - HIDDENFor the DoctorSelect the quantity of the item(s) you'd like to order.Newborn to Child Techniques DVD0123456789Subscribe to the Wellness Education Club or purchase the Adjusting Technique DVD. ON BACKORDER Subscribe to the Wellness Education Club or purchase the Adjusting Technique DVD.The Wellness Education Club 1 Year Subscription +$299.00 Newborn to Child Techniques DVD +$170.00 Case History Sheets (50 per pad)0123456789Exam Sheets (50 per pad)0123456789This field is hidden when viewing the formFor the Doctor Subtotal - HIDDENFor the OfficeSelect the quantity of the item(s) you'd like to order.Welcoming Wellness DVD0123456789Wellness Pamphlets (25 each)Pregnancy Pamphlets0123456789Infant Pamphlets0123456789Toddler Pamphlets0123456789Pre-Schooler Pamphlets0123456789School Age Pamphlets0123456789Teen Pamphlets0123456789Sensory Processing Disorder Pamphlets0123456789Set of first six pamphlets0123456789Set of all seven pamphlets0123456789This field is hidden when viewing the formFor the Office Subtotal - HIDDENFor Your CommunitySelect the quantity of the item(s) you'd like to order.PowerPoint Packages Children and Chiropractic Care (Binder Package) Children and Chiropractic Care (Digital Download) The Wellness Pregnancy (Binder Package) The Wellness Pregnancy (Digital Download) This field is hidden when viewing the formFor Your Community Subtotal - HIDDENSubtotalShipping and Handling Charges$15Shipping and Handling Charges$20Shipping and Handling Charges$25TotalOrder Breakdown Price: $0.00 Credit Card InformationWe accept VISA, MasterCard, American Express and DiscoverCredit Card #*Security Code*Expiration Date*Untitled Check if Credit Card Billing Address is same as above Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Actual price is TO BE DETERMINED due to international shipping. International orders are subject to additional shipping costs, you will be contacted by a representative via email shortly.All prices in US Dollars. All orders are shipped via USPS Priority Mail within 2 business days unless requested otherwise. Rush orders are shipped via Fed-Ex and are subject to additional shipping and handling charges based on the actual cost of shipping. International orders are subject to all applicable duties, tariffs and shipping and handling charges based on weight and cost of shipping.Wellness Education Club SubscriptionI agree that I am committing to a one-year subscription to the Wellness Education Club. I know that my credit card will be charged each month on the 1st for $30. After the first year, it becomes a month-to-month subscription that I can end at any time. I also understand that if my credit card is declined that I will not receive my monthly materials until that payment has been made.* I accept the renewal policy. I agree that I am committing to a one-year subscription to the Wellness Education Club and that it is automatically renewed annually for $299 per year. Notification of upcoming renewal is sent eight weeks prior and no refunds will be provided after it has been processed.* I accept the renewal policy. Wellness Family Newsletter SubscriptionI agree that the Wellness Family Newsletter subscription is automatically renewed annually for $120 per year. Notification of upcoming renewal is sent eight weeks prior and no refunds will be provided after it has been processed.* I accept the renewal policy. Did You Know SeriesI agree that the Did You Know Series subscription is automatically renewed annually for $199 per year. Notification of upcoming renewal is sent eight weeks prior and no refunds will be provided after it has been processed.* I accept the renewal policy. Add any comments you would like submitted with this order.
