Order by MAIL or FAX with this HIProtector® order form! Print this ORDER FORM on your browser (click print icon). Fax (781) 235-3252 or Mail it to us at the address below. Please include your check with the order. Call (800) 930-9255 for questions. 30-Day Money Back Guarantee! Name.....:_______________________________________________ Address..:_______________________________________________ City.....:_____________________________ Zip......:________________State or Country:______________________ Payment by: ___ Check/Money Order enclosed ___ Charge my credit card ___ MasterCard ___ VISA ___ AMEX ___ Discover ___ Diner's Club |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|__| Exp. Date: _________ Signature: _____________________________ Please send me: (We can ship to a different address - please indicate) Please note that the none of the hip protectors on the US market have been approved by the FDA (Food and Drug Administration) for the prevention of hip fractures. _____ HIPS WOMEN's Complete 3-UNIT-KIT (3 pairs of HIPS underwear + 1 pair of HIPS hip protectors)(Price: $174.95). Size: ______ Waistline: Small (25"-29"), Medium (30"-32"), Large (33"-34"), X-Large (35"-36"), XX-Large (37"-39") _____ HIPS WOMEN's Extra Panties (2 pairs of HIPS special underwear)(Price $47.95) Size: ____ Waistline: Small (25"-29"), Medium (30"-32"), Large (33"-34"), X-Large (35"-36"), XX-Large (37"-39") _____ HIPS MEN's Complete 3-UNIT-KIT (3 pairs of HIPS underwear + 1 pair of HIPS hip protectors) (Price $174.95) Size: ____ Waistline: Small (29"-33"), Medium (34"-36"), Large (37"-39"), X-Large (40"-43"), XX-Large (44"-46") _____ HIPS MEN's Extra Briefs (2 pairs of HIPS special underwear) (Price $47.95) Size: ____ Waistline: Small (29"-33"), Medium (34"-36"), Large (37"-39"), X-Large (40"-43"), XX-Large (44"-46") _____ SAFEHIP WOMEN's (One Pair with Built-In Hip Protectors) Size: ____ (Price: $89.95) Size: X-Small (24"-27"), Small (28"-31"), Medium (32"-34"), Large (35"-37"), X-Large (38"-44") _____ SAFEHIP MEN's (One Pair with Built-In Hip Protectors) Size: ____ (Price: $89.95) Size: Small (28"-31"), Medium (32"-34"), Large (35"-37"), X-Large (38"-44") _____ HipGuard (Uni-Sex) Hip Protector Belt (External Hip Protector) Size: ____ (Price: $129.95) Small (31"-34" hip-line), Medium (35"-41" hip-line), Large (42"-50" hip-line) ______ Mass. Residents please add 5% sales tax. FREE Standard Shipping and Handling (US Customers Only) _____ ORDER TOTAL MAIL ORDERS:e-pill, LLC | HIProtector® 70 Walnut Street Wellesley, MA 02481, USA http://www.HIProtector.com FAX ORDERS: Fax: (781) 235-3252 PHONE ORDERS: 1-800-930-9255 Call for shipping outside the USA. How much is Shipping & Handling? We accept credit cards: AMEX, Visa, MasterCard, Discover, Diner's Club 30-Day Money Back Guarantee. e-pill, LLC makes no implied or express guarantee that its products or devices will prevent injury. Please note that none of the hip protector products on the US market have been approved by the FDA (Food and Drug Administration) for the prevention of hip fractures. HIProtector® Living With Fewer Anxieties About Falling™ HIPS™, SAFEHIP®, HipGuard™ & CuraMedica® Regain Confidence - Prevent Inactivity! e-pill, LLC | HIProtector® 70 Walnut Street Wellesley, MA 02481, USA www.HIProtector.com (781) 239-8255 | 1-800-930-9255 | fax (781) 235-3252 e-pill, LLC or HIProtector is not a Medicare Provider and does not bill Medicare. If you are a Medicare recipient you assume complete financial responsibility for your purchases. Copyright 2001,2002,2003,2004,2005,2006,2007