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Customer Information / New Customer

First Name :		E-Mail :
Last Name :		Phone :

Billing / Shipping Address

Billing Address	Shipping Address
Where is your credit card statement sent?		Shipping Address is the same as my Billing Address
Billing Address :	Shipping Address :
Billing City :	Shipping City :
Billing State :	Shipping State :
Billing Zipcode :	Shipping Zipcode :
Billing Country :	Shipping Country :
	Shipping Name (if different than customer name) :

Credit / Debit-Card Data

Type of Card:
Credit/Debit Number (no spaces, no dashes) :
Expiration Date :	/
Card Code (3 digits) :
Cardholder Name :
Your Card will be charged by our Billing Service Provider LazarusLabs.com

Terms & Conditions

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LAZARUS LABS
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Customer Responsibility, Informed Consent Statements and 
Terms & Conditions of Sale of any and all products listed below:
* Phentramin-d
* Phentramin
* Zanaprin
* Hoodia HG57
* Lazarus Acai Plus
* Tramaden
* Glycemil
* LipoStatin
* Natural Champion X-Treme Performance Enhancement Products
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BY SUBMITTING THIS ORDER, 
I AFFIRM AS IF UNDER OATH AND STATE TRUTHFULLY THAT:

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I am an adult aged 18 years or older and I am purchasing this product out of my own free will, at my own expense and my own liability and assume all responsibility for the use of this product.

I am requesting this product solely for my own personal needs, and will not distribute it to others.

I am aware that I am not ordering a prescription item.
 
I fully understand that the company cannot guarantee the results I seek.

I acknowledge that no guarantees have been made to me as to the results as there is no known product that gives 100% satisfaction to everyone, nor are there any guarantees against unfavorable results, risks or complications.

I understand that I am buying this product with the full knowledge that I may not benefit from its use.

I have full knowledge that no one can predict as to whether I would or would not have any adverse effects since every individual has a unique biological/chemical make-up. I understand that all possible risks and/or complications do not need to be explained to me, nor do I consider this practical or even possible because risks and complications may occur that have never been recorded before. I hereby release LazarusLabs.com and all of its employees and contractors from any and all liability whatsoever associated or connected with the use of any of their products and any adverse effect that I may suffer from consequently, if any, on account of the use of their products. I am solely responsible for any adverse effects I may suffer from taking or continuing to take any of these products.

I agree to promptly contact my local physician for any necessary care and medical intervention in case I have any difficulties or possible complications as a result of use of any of the products listed above. I further agree that it is my responsibility to have routine physical examinations to ensure that I have no diseases and to ensure that no adverse effects develop on account of my using any of these products. I further agree to immediately notify my doctor, whose present care I am under, that I have chosen to take any or all of the products listed above.

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Credit Card Billing
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I authorize you to charge my credit card towards the price of the product(s) and any shipping fees as well as any other fees that you may charge to fulfill my order. I am aware that my Credit Card statement will reflect the charge by your company LazarusLabs.com.

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Return Policy
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I understand that all sales are final. 
I further understand that I cannot cancel my order or request a refund once the package is shipped. 
I am fully aware that NO refund is given if I change my mind and decide not to take the product or upon my physician�s opinion that I should no longer take the product. 
I realize that if I have mistakenly provided an incorrect address, and the order was shipped to that address, I will receive no refund at all.

I hereby declare that I have read this document fully, understand it well and totally agree with the terms & conditions set forth herein.

I wish to purchase this product and proceed to the checkout page.

I hereby declare that I have read this document fully,
understand it well and totally agree with the Terms & Conditions set forth herein.
I accept all Terms & Conditions and wish to proceed with this order :

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