DYNAWAVE ORDER FORM

Mail to:	            		      By phone:	     		         

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

Ship to: ____________________________________________________________

Company: ____________________________________________________________

Street Address: _____________________________________________________

City: ___________________Prov./State: ______Postal Code: ____________

Phone: ____________________ E-mail: _________________________________


Quantity    Description		    Price	    Extended
-----------------------------------------------------------------
________  CellStim 400T	           $630.00         ___________
          Clinician portable model

________  CellStim 600	           $480.00         ___________
          Patient portable model

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

________  Chiropractic Microcurrent
 	  Seminar  Video    DVD    $90.00          ___________
				      
				         Subtotal: ___________

             			        Shipping:  ___________
		   
				             TOTAL:___________
Prices are in US 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: _________________________________________________________