Harris International Health Care, Ltd.
10115 Towhee Avenue
Adelphi, Maryland 20783-1209
Phone: 
FAX: 800-841-5199

Ship to:
Name:          __________________________________________________
Organization:  __________________________________________________
Address:       __________________________________________________
City: _____________________   State: ____________ ZIP: __________
Telephone:   (____)______________________________

   Item Description       Quantity         Unit Price     Total Price

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Shipping and Handling                         Subtotal    ______________
  Up to $50.00    $5.95    MD residents only sales tax    ______________ 
  Over $50.00 $7.55           Shipping & Handling    ______________
                                Grand Total    ______________
  For overnight and two-day
  shipping, please inquire.


Payment Method (circle one):

VISA, M/C, AMEX, CHECK

Make checks payable to HIHC, Ltd.

Credit Card No.: __________________________   Expiration Date __________

Signature: __________________________ (required for credit card orders)




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ECONOMY TRAVELER HEALTH KIT

	INDIVIDUAL WITHOUT DENTAL	$41.95
	INDIVIDUAL WITH DENTAL		$51.95


TRAVELER HEALTH KIT

	INDIVIDUAL			$57.20 
	INDIVIDUAL w/DENTAL		$67.70



POCKET HEALTH KIT

	INDIVIDUAL			$15.95 

DENTAL EMERGENCY KIT (VIAL)		$18.10
DENTAL EMERGENCY KIT (FLAT BOX)		$18.10