NOTE: This form is for US RESIDENTS only!!

DUTCH PLUS - US
Secure Enrollment Form

Thank you and congratulations! You've chosen to give yourself the gift of leaping forward to new levels of health and well being.

To avoid any ordering problems, please use only your first and last name (NOT your middle initial or middle name), and make sure all fields are filled out completely.

Be sure to use the address that your credit or debit card is linked to even if that's different from your physical address.

If you have any difficulties, contact us at [email protected] and we'll help you with your order.

With love, health and Joy,

Dr. Ritamarie

Products Price Quantity Total

Products		Price	Quantity	Total
Lab Testing: Precision Analytical - DUTCH PLUS - US The DUTCH Plus™ offers an extensive assessment of sex and adrenal hormones and their metabolites. It also offers an assessment of the Cortisol Awakening Response (CAR).	$400.00	Update	$400.00
Subtotal			$400.00

Lab Testing: Precision Analytical - DUTCH PLUS - US

The DUTCH Plus™ offers an extensive assessment of sex and adrenal hormones and their metabolites. It also offers an assessment of the Cortisol Awakening Response (CAR).

$400.00

Update

$400.00

Subtotal $400.00

Billing Information
* First Name
* Last Name
Company Name
* Address - Line 1
Address - Line 2
* City
State
* Zip Code
* Country
* Phone Number
* Email Address
Shipping is the same as billing

Shipping Information
* First Name
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Address - Line 2
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Shipping Options
$0.00 Domestic US Shipping

Payment Plans
Single payment of $400.00

Order Summary
Subtotal	$400.00
Order total	$400.00
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Sales Terms of Agreement :

I authorize Dr. Ritamarie LLC to charge me for the order total listed above and agree to remit a payment to Dr Ritamarie LLC. I further affirm that the name and personal information provided on this form are true and correct. I further declare that I have read, understand and accept Dr. Ritamarie LLC's business terms as follows.

The products and services to be purchased in this transaction are owned solely by Dr Ritamarie, LLC and can only be used by the purchaser for his/her own use and education. These products and services cannot be used for any other purpose, including, but not limited to: resale, posting on web or social media sites, licensing or any commercial transaction without the written consent of Dr Ritamarie, LLC.

'Changing Lives with Root Cause Health Care'