Or, Print, Fill out, and Mail or fax the following form to

Peter H. Proctor, PhD, MD
Suite 1616, 4126 SW Freeway
Houston, Texas 77027

Office: 713-960-1616
FAX: 713- 960-9307
1-800-926-1752 (Voice line for orders only)

We accept credit cards, checks, or money orders in US currency only. Note: Canadian and some European post offices sell US dollar-denominated postal money orders. We also accept Western Union International Money Grams ( fax or e-mail us the number )

Name:________________________________________
Street Address___________________________________
City__________________________St.________ postal code______________
Country______________
Credit card #___________________________________________Expires________
Card Member's signature__________________________________
Phone__________________________________
Proxiphen-N (nonprescription ) 2 Months $59.95 ________
4 Months supply $109.95 _________
NANO Shampoo 3 Months supply $39.95 _________
NANO Conditioner 2 Months supply $29.95 ___________

NANO Shampoo and Conditioner $59.95_____________ ($10 Price Savings)
Proxiphen ( Prescription ) 1 Month $100.00_____________
(Requires physican diagnosis---Read first )

Shipping and Handling $3.00________
(Airmail to Europe or Asia is typically $10-15 US, about $25 for express. Orders to Italy are sent express only. Minimum order to Italy is $100 plus shipping )

Total ____________