DYNAWAVE ORDER FORM

Mail to:	            		      By phone:	     		         

DYNAWAVE Medical Technologies Inc.          (604) 875-8599                     
4386 Strathcona Road       		    
North Vancouver, BC V7G 1G3

Ship to:

Name: _______________________________________________________________

Company: ____________________________________________________________

Street Address: _____________________________________________________

City: ___________________Prov./State: ______Postal Code: ____________

Phone: ____________________ E-mail: _________________________________


Quantity    Description		                  Price per Unit
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________  CellStim 400T	  				795.00         
          Clinician portable model

________  CellStim 400	  				630.00         
          Clinician portable model          
          
________  CellStim 600	           	                580.00
          Patient portable model

________  Self-Adhering pads (4)                         15.00
          High quality multi-use
          2" round cloth

________  Chiropractic Microcurrent                      90.00
 	  Seminar  Video    DVD    
				      
				 Subtotal: ___________
             		         Shipping: ___________		   
                  BC residents only PST 7% ___________
                 Canadian residents GST 5% ___________
             		             	         
                                     TOTAL:___________
                                     
Prices are in $CDN funds.  Please make cheques payable to: DYNAWAVE Medical Technologies Inc.


_____Ship using courier account #:______________________________

_____Check or Money Order Enclosed

Credit Card:  _____Visa  _____MasterCard   _____American Express

Card Number: ___________________________________________________

Expiration Date: ________________

Signature: _____________________________________________________