Order Form

Order Information for RenaPlex^®, MagneBind^® 300 and Calphron^®

Please enter all information, print form, then mail with your check* or money order (made payable to Nephro-Tech, Inc.) to:

Nephro-Tech, Inc.

P.O. Box 16106

Shawnee, KS USA 66203

We now accept MasterCard, Visa and Discover. Call 800-879-4755 to charge by phone.

First Name Last Name

Street Address

CityState Zip Code

E-Mail Address Home Ph.

*ALL ORDERS ARE A MINIMUM OF 2 BOTTLES EACH PLEASE*

Product(s): Cost: Quantity: Total Cost (Cost x Quantity)

RenaPlex^® (1 to 23 bottles) $9.00/100 tablets

(24 and above) $7.50/100 tablets

MagneBind^® 300 $15.75/150 tablets

Calphron^®^{^} $15.00/200 tablets

^Special case pricing available Total:

Kansas residents only multiply total by .07 for sales tax + shipping and handling per order (not per bottle!) + $4.95

*Free shipping for orders of 24 or more bottles*

Total Cost for Order:

*When paying with a check, product will not be shipped until check has cleared the bank. When paying with a money order, product will be shipped immediately upon receipt of order. Please make checks payable to Nephro-Tech, Inc.