ORDER FORM

PLEASE PRINT Fill e mail or  FAX THE FORM TO US.

Guardian                Angle	7- 73 Capital Hill Midrand  South Africa E-mail: icm@lantic.net
Tel:	( 27) 011- 312 3393
:	www.gagacure.co.za

CLIENT INFORMATION: ( Please use only black pen and write in capital letters)

Name:	_________________________	Telephone No:	( )___________________
Postal Address:	____________________	Fax No:	( )___________________
	____________________	Cell No:	____________________
	____________________	E-mail:	________________________

 In South Africa, advance payment info: B.Ashoori  FNB Bank Checking Account # 62759455077 Branch Code: 250 655

Please fax the deposit slip to: (011) 312 4877      

It is better to let us know your health problem as well............................................................................

No	ITEM	QUANTITY	PRICE	TOTAL
			Total:
Add 30 for courier in South Africa			Courier	R145
Balance due:

Signature:________________________ Date: ______ / ______ / ________ Place:

Please note By law only Medical doctors are allowed to diagnose and do treatment. Also registered pharmaceutical Medi*ines recommended by Medical doctors must be used. Please do not contact us if you have not already tried orthodox way of treatment. Do not discontinue your medication. We may suggest special natural diet or complementary supplements that we suggest you check with your Medical doctor before use.