I.B.S. CHALLENGE ENTRY FORM

To participate in the IBS Challenge or to become a sponsored member of a IBS Support Group please fill out the entry form below completely or call 1-877-877-4059 to register. In seven to ten days you will receive your IBS Challenge kit which will include a IBS Self-Evaluation Questionnaire and 1 bottle of Regimint. When redeeming the 1 month supply of Regimint simply provide $4.95 to help cover the cost of shipping and handling. For residents in Canada $6.00 (US currency only) and the UK please provide $9.00 (US currency only) to help cover shipping and handling.  

Please provide the following contact information:

Name
Name of IBS Support Group
Address
City
State/Province
Zip/Postal Code
Country
Home Phone
FAX
E-mail

Please identify and describe yourself:

           Diagnosed For I.B.S.?       Yes      No               

           Which symptom do you have?       Diarrhea         Constipation

Age
Sex Male Female
PAYMENT  INFORMATION:

         

          CARD NUMBER

           9999/9999/9999/9999/

         

 

          EXPIRATION:

 

             Month       Year         

           

 

 

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All information obtained will remain confidential and will not be shared with any other company.
Copyright © 2003 [Cutting-Edge Herbal Products, Inc.]. All rights reserved.
Revised: 12/08/11