Standard Process Purification Order Form - Access Complete Wellness

First & Last Name

Phone Number

Emailan email you check

Address

City, State, Zip

Genderpick one!

MaleFemale

Vegetarian?pick one!

YesNo

Gluten Free?pick one!

YesNo

Dairy Free?pick one!

YesNo

If you are Dairy free, there are two options for you below noted as Dairy Free.

Which Purification Program do you want?

Do you crave sugars and/or carbohydrates like breads, pastas or sweets often during the day? If so, you may want to order an herb called Gymnema during the cleanse to assist you with cravings. Would you like that included for the cost of $22.00?

Gymnemapick one!

YesNo

You will need to be taking a quality fish oil for the cleanse, do you need one provided for you? If yes, would you like that included in your order for the cost of $25 minus any specials that may be running?

Fish Oilpick one!

YesNo

Will you be picking this order up at our office or are we drop-shipping this to you at the address you provided above? If yes, include a $13 drop-ship fee.

What is your expected start date for your 21 Day Purification Program? This date will be used to start your Purification Email Support Program. The date can be changed if you start on a different date.

Date to start the program

Important: Sales tax will apply in states outside of Texas as applicable.

Shortly after you submit this form you will receive an invoice for the total amount of your order from Access Complete Wellness from this email address: invoicing@messaging.squareup.com. Once the invoice has been paid your order will be processed.