South African orders ONLY
PAYMENT FORM

FAX and EMAIL of Payment, Credit Card and electronic payment (EFT) orders

FAX Number 086-542-0381 - Email orders@agelesshealth.co.za

CREDIT CARD
If you choose to pay by Card, we will send you an SMS with a payment link for you to complete payment.

ELECTRONIC PAYMENT
if paying by EFT (Electronic Fund Transfer) complete the order form and fax or email it to us and tick the EFT payment block below and please use your Cellphone number or Name and Surname as reference when transferring money and mail orders@agelesshealth.co.za or fax (086-542-0381) the proof of payment to us. 

Our banking details:  First National Bank, Sallamander Concepts, Branch Code 250-655, Account Number 62268080109 or see our details here

PRODUCT PAGE

Please debit my credit card

We will send you a payment link via SMS

 

I will be transferring funds via EFT

 
 

Name

 
 

e-mail address

 
 

Contact Cellular Number :

 
 

Delivery address - South Africa (see information...)

 
 
 

Postal code (we need it for courier delivery as well)

 

Item

Quatity

Price

Total

   

R

R

   

R

R

   

R

R

   

R

R

   

R

R

DELIVERY (Courier or Speed Services Counter) We will provide you with a QUOTE

R

TOTAL DUE

R