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Order Form for RenaPlex^®, RenaPlex^®-D, MagneBind^® 300 and Calphron^®

Please print form first then enter all information and mail to:  

Nephro-Tech, Inc., P.O. Box 16106, Shawnee, KS 66203

First Name________________________    Last Name_______________________________  

Mailing address ______________________________________________________ 

City_______________________ State__________    Zipcode________________  

Phone(_______)_____________________

Product                                  Cost                                  # of Bottles            Total

Call 1-800-879-4755 for case pricing information                                          (Cost x Bottles)

RenaPlex^®                  $9.00 per bottle (100 tablets)       _______       _______________  

RenaPlex^®-D             $12.00 per bottle (100 tablets)      _______       _______________  

MagneBind^® 300      $15.75 per bottle (150 tablets)       _______       _______________  

Calphron^®                  $15.00 per bottle (200 tablets)      _______       _______________

                                                            Subtotal:        _______________

 Prior Balance:(Overpaid-)Underpaid+                                              - /+ _______________

 Kansas residents only - Multiply subtotal by .07 for sales tax                 +  _______________

 Shipping and handling (per order, not per bottle)                                    4.95         

                                         Total Cost of Order:       ____________  

If paying with check or money order, make payable to Nephro-Tech, Inc.  If paying with credit card, call 800-879-4755 OR complete information below:  

__ __ __ __   __ __ __ __   __ __ __ __    __ __ __ __  __________  ___________________

 Credit Card # (16 numbers)                       Exp (mo/yr)      Your signature

(Mastercard, Visa, Discover Only)