Fillable Printable Order Form Sample
Fillable Printable Order Form Sample
Order Form Sample
Step Two: Enter your order below
Order Form
Step One: Enter your shipping address and contact information below.
Client Name Client ID #
Address
City State Zip
Phone # Email
Health Coach ID #
Referred By (Client name and ID #)
Item # Product Description Price QTY
Maintenance Bar (limit to one per day on the 5 & 1 Plan
®
)
65440 Caramel Nut Maintenance Bar $18.25
Soups - 7 servings/box
69660 Beef Vegetable Soup $18.25
69650 Wild Rice & Chicken Flavored Soup $18.25
69600 Chicken Flavored Noodle Soup $18.25
69670 Maryland Style Crab Soup $18.25
52700 Tomato Basil Bisque Soup $18.25
Oatmeal - 7 servings/box
58000 Apple Cinnamon Oatmeal $18.25
58010 Blueberry Oatmeal $18.25
58020 Maple & Brown Sugar Oatmeal $18.25
58030 Peach Flavored Oatmeal $18.25
Pancakes - 7 servings/box
57700 Original Pancakes $18.25
57710 Chocolate Chip Pancakes $18.25
57720 Spiced Pancakes $18.25
Eggs - 7 servings/box
57800 Original Style Eggs with Egg Whites $18.25
57810 Southwest Style Eggs with Egg Whites $18.25
Soft Bakes - 7 servings/box
57530 Gingerbread Soft Bake $18.25
57500 Brownie Soft Bake $18.25
57510 Chocolate Chip Soft Bake $18.25
57520 Blueberry Muffin Soft Bake $18.25
Soft Serve - 7 servings/box
57610 Peanut Butter Soft Serve $18.25
57620 Chocolate Mint Soft Serve $18.25
57630 Mango Soft Serve $18.25
57600 Coffee Soft Serve $18.25
Cereal Crunch - 7 servings/box
68400 Cinnamon & Brown Sugar Cereal Crunch $18.25
68300 Mixed Berry Cereal Crunch $18.25
Crunchers - 7 servings/box
Pretzel Sticks
68250 Cinnamon Pretzel Sticks $18.25
68260 Honey Mustard Pretzel Sticks $18.25
Bites
68230 BBQ Bites $18.25
68240 Cheese Pizza Bites $18.25
Cheese Puffs
67245 Chili Nacho Cheese Puffs $18.25
67235 Parmesan Cheese Puffs $18.25
Optimal Health by Take Shape For Life
™
- 7 servings/box
65561 Dark Chocolate Dream Bar $18.95
65566 Salted Caramel Nut Bar $18.95
65571 Strawberry Yogurt Bar $18.95
52546 Chocolate Peanut Butter Shake $18.95
73006 Cookies & Cream Shake $18.95
73011 Piña Colada Smoothie $18.95
52516 Strawberry Banana Smoothie $18.95
74814 Optimal Health Kit (4 Weeks) $297.65
Page 1 Subtotal
Item # Product Description Price QTY
Shakes - 7 servings/box
52550 Dutch Chocolate Shake $18.25
52500 French Vanilla Shake $18.25
52510 Strawberry Shake $18.25
52520 Orange Cream Shake $18.25
52540 Mocha Shake $18.25
52530 Banana Shake $18.25
Antioxidants Shakes (whey-based) - 7 servings/box
72660 Cherry Pomegranate Antioxidant Shake $18.25
72670 Dark Chocolate Antioxidant Shake $18.25
Ready-to-Drink Shakes - Singles
68700 Dutch Chocolate Ready-to-Drink Shake $3.35
68800 French Vanilla Ready-to-Drink Shake $3.35
68900 Mocha Ready-to-Drink Shake $3.35
Ready-to-Drink Shakes - Cases (24 singles/case)
68700 Dutch Chocolate Shake Ready-to-Drink Shake $66.75
68800 French Vanilla Shake Ready-to-Drink Shake $66.75
68900 Mocha Shake Ready-to-Drink Shake $66.75
Smoothies - 7 servings/box
72870 Triple Berry Smoothie $18.25
72880 Pineapple Mango Smoothie $18.25
Hot Drinks - 7 servings/box
57300 Hot Cocoa $18.25
57350 Cappuccino $18.25
57360 Chai Lattè $18.25
72630 Calorie Burn Cappuccino $18.25
Quenchers - 7 servings/box
66560 Tropical Punch Fruit Drink $18.25
66570 Cranberry Mango Fruit Drink $18.25
66580 Orange Blend Drink $18.25
Hearty Choices - 7 servings/box
66590 Hearty Vegetarian Sloppy Joe $18.25
66595 Macaroni & Cheese $18.25
66610 Sour Cream & Chive Mashed Potatoes $18.25
66615 Garlic Mashed Potatoes $18.25
66650 Ziti Marinara $18.25
69700 Vegetable Chili $18.25
Pudding - 7 servings/box
57400 Chocolate Pudding $18.25
72850 Banana Pudding $18.25
57410 Vanilla Pudding $18.25
Bars - 7 servings/box
Crunch Bars
64905 Chocolate Mint Crunch Bar $18.25
65005 Peanut Butter Crunch Bar $18.25
65445 Caramel Crunch Bar $18.25
65405 Oatmeal Raisin Crunch Bar $18.25
64805 Chocolate Crunch Bar $18.25
65455 S’more Crunch Bar $18.25
65520 Strawberry Crunch Bar $18.25
65510 Cinnamon Roll Crunch Bar $18.25
65505 Fruit & Nut Crunch Bar $18.25
65205 Lemon Meringue Crunch Bar $18.25
Chewy Bars
65556 Cookie Dough Chewy Bar $18.25
64955 Peanut Butter Chocolate Chip Chewy Bar $18.25
❑
Client wants to enroll in BeSlim
®
Club
❑
Client Declines BeSlim
®
Club offer
❑
Client already BeSlim
®
Club Member
Prices subject to change.
Step Three: Enter your billing information below.
Name On Card ______________________________________________________________________________________________________________________________________
Phone ___________________________________________________________________ Address _________________________________________________________________
City _____________________________________________________________________ State __________ Zip ____________________________________________________
Step Four: Enter your credit card information below. (
Sorry, no checks or CODs. Don’t forget to sign and date below.)
Visa
❑
MC
❑
Amex
❑
Disc
❑
Credit Card No. _______________________________________________________ Exp. Date ________________ Security Code _____________________________
Signature _________________________________________________________________________________________ Date ______________________________________
SHIPPING: All non-expedited orders ship standard ground rates through a
common carrier. Receive reduced or free shipping on every BeSlim
®
Club
order over $150 within the continental U.S.
*
Please note: For non-BeSlim
®
Club orders, expedited shipping is at full
cost, regardless of order total. *To be an active BeSlim
®
Club member and
receive all benefits, an order is required to be placed every 60 days. See
BeSlim
®
Club Terms and Conditions for full details.
ORDER TOTAL
SUBTOTAL ______________________
- COUPON ______________________
+ SHIPPING _____________________
TOTAL _____________________
Item # Product Description Price QTY
Flavors of Home
™
Meals
66605 Turkey Meatball Marinara $4.95
66630 Chicken with Rice & Vegetables $4.95
66625 Chicken Cacciatore $4.95
66620 Beef Stew $4.95
Snacks - 7 servings/box
Veggie Chips - These are not Take Shape For Life Meals.
57275 Sea Salt & Olive Oil Veggie Chips $7.95
57255 Spicy Black Bean Veggie Chips $7.95
Popcorn - These are not Take Shape For Life Meals.
52650 Sea Salt Popcorn $7.95
52640 Cheddar & Sour Cream Popcorn $7.95
Snack Variety Pack - 16 servings/box
75757 Snacks Variety Pack $18.95
Soy Crisps - These are not Take Shape For Life Meals.
57270 Apple Cinnamon Soy Crisps $7.95
57260 Ranch Soy Crisps $7.95
57250 White Cheddar Soy Crisps $7.95
Crackers - These are not Take Shape For Life Meals.
57235 Multigrain Crackers $7.95
57245 Rosemary Sea Salt Crackers $7.95
Habits of Healthy Sleep
75049 Sleep Set $99.00
75045 Sleep Set with Far-Infrared Blanket $399.00
0169 Melatonin $28.95
72680 Restfulmind
™
Herbal Sleep Tea $15.95
50050 Sleep Mask & Ear Plugs in Plush Pouch $39.15
50075 Far-Infrared Blanket $349.00
Dr. A’s Habits of Health
32700 Discover Your Optimal Health (Book) $13.95
32701 Dr. A’s Habits of Health (Book) $29.95
32702 Living a Longer Healthier Life (Companion Guide) $17.95
32703 Dr. A’s Habits of Health Video Series Vol. 1 & 2 $14.95
74890 Habits of Health System $74.95
BeSlim
®
30 Day Kits
75056 BeSlim
®
30-Day Favorites Kit $310.25
75051 BeSlim
®
On-the-Go Lifestyle Kit $310.25
75061 BeSlim
®
30-Day Variety Kit $310.25
75130 BeSlim
®
30-Day Optimal Favorites Kit $346.25
Optimal Health Kit (4 Weeks)
74814 Optimal Health Kit $297.65
Extras
Syrup - 7 servings/box
57750 Sugar-Free Syrup $4.65
Infusers/Drops
Flavor Infusers
™
- 21 servings/box
72690 Mandarin Orange Energy Infuser $17.50
72700 Unsweetened Lemon Energy Infuser $17.50
Energy Drops - 24 servings
52630 Pineapple Mango Energy Drops $5.95
52625 Wild Strawberry Energy Drops $5.95
52635 Lemonade Energy Drops $5.95
Energy Drops Variety Pack - 72 servings/kit
75765 Energy Drops Variety Pack $14.95
Essential1
®
: Calorie Burn Flavor Infusers
™
- 21 servings/box
72600 Essential 1: Calorie Burn Green Tea Lemon Flavor Infuser $17.50
72620 Essential 1: Calorie Burn Strawberry Lemonade Flavor Infuser $17.50
72610 Essential 1: Calorie Burn Mixed Berry Flavor Infuser $17.50
Item # Product Description Price QTY
Essential1
®
: Calorie Burn Flavor Infusers
™
- 21 servings/box
72600 Essential 1: Calorie Burn Green Tea Lemon Flavor Infuser $17.50
72620 Essential 1: Calorie Burn Strawberry Lemonade Flavor Infuser $17.50
72610 Essential 1: Calorie Burn Mixed Berry Flavor Infuser $17.50
Essential1
®
: Antioxidants Flavor Infusers™ - 21 servings/box
72640 Essential 1: White Grape Peach Flavor Infuser $17.50
72650 Essential 1: Raspberry Açai Flavor Infuser $17.50
Essential1
®
: Antioxidants Flavor Infusers™ - 21 servings/box
72640 Essential 1: White Grape Peach Flavor Infuser $17.50
72650 Essential 1: Raspberry Açai Flavor Infuser $17.50
Essential1
®
Dietary Supplements
0163 Heart Health - 60 capsules/bottle $25.65
0165 Digestive Health - 30 packets/box $25.65
BeSlim
®
Club Exclusive Offers
(Offered only for BeSlim Club orders above $310. These exclusive offers are non-returnable.)
74881 Dr. A’s Habits of Health Bundle (25% Off) $36.00
75761 Snack and Boost Pack (31% Off) $24.99
75378 Soup and Cracker Bundle (23% Off) $40.00
74949 Warm Up Bundle (26% Off) $40.00
Fitbit
®
75200 Flex
™
Wireless Activity + Sleep Wristband (Teal) $99.95
75215 Flex
™
Wireless Activity + Sleep Wristband (Black) $99.95
75205 One
™
Wireless Activity + Sleep Tracker (Black) $99.95
75225 Zip
™
Wireless Activity Tracker (Black) $59.95
75190 Aria
™
Wi-Fi Smart Scale (Black) $129.95
75235 Surge
™
Fitness Super Watch (Black Small) $249.95
75180 Surge
™
Fitness Super Watch (Black Large) $249.95
75150 Charge HR
™
Heart Rate + Activity Wristband (Black Small) $149.95
75140 Charge HR
™
Heart Rate + Activity Wristband (Black Large) $149.95
75170 Charge
™
Activity + Sleep Wristband (Black Small) $129.95
75160 Charge
™
Activity + Sleep Wristband (Black Large) $129.95
50212 Stickers to Customize Your Fitbit
®
$0.99
Program Accessories & Materials (All program materials are sold individually.)
31239 Product and Program Catalog $2.00
31239 Product and Program Catalog (pack 5) $8.50
31244 Discover Take Shape For Life Brochure (pack of 25) $4.00
31249 Healthy Body Brochure (pack of 25) $4.00
32510
Shaker Jar
$1.99
32505 BlenderBottle
®
$7.50
50155 Medifast Blender $39.95
50121 Coffee Mug $3.95
42331 Lean & Green
™
Meal Cookbook $12.95
41880 Dining Out Guide $1.00
41031 Quick Start Guide $1.00
41071 Exercise Guide $1.00
37880 Diabetes Guide $0.00
37936 Senior Guide $0.00
41111 Teen Guide $1.00
32775 Food Journal $1.00
32283 Habits of Health Magnets $9.95
Subtotal from this page
+ Subtotal from page 1
= Subtotal
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