Irlen Diagnostic Center of North Carolina

Irlen Diagnostic Clinic of North Carolina 212 Epping Road, Clemmons, NC 27012 fax: (336) 766-1487/cel: (336) 403-2524 [email protected] 5/1/2016 Assorted Overlays $2.75/each

AQUA ______

BLUE-GRAY ______

GOLDENROD ______

GRAY ______

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PEACH ______

PURPLE ______

ROSE ______

TURQUOISE ______

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Total overlays: ______X $2.75

$ ______

IRPS forms ( packages of 50) X $22.00 = + $______

SHIP TO:______Total: $ ______

______NC Orders only: Sales Tax (6.75%) $______Shipping: $______Estimated Shipping cost: *For orders of $200 or more add 5% to the shipping cost. Total: $ ______Cost of Order S/H Fee $ 0 - $ 24.99 $ 5.95 $ 25.00 - $ 55.99 $ 7.95 $ 56.00 - $ 75.99 $10.95 Date ordered: $ 76.00 - $ 99.99 $11.95 $ 100.00 - $299.99 $12.95 $ 300.00 - $599.99 $19.95 $ 600.00 - $999.99 $36.95 $`1,000.00+ $40.95 OVERLAYS THAT ARE TO BE EXCHANGED MUST BE RETURNED WITHIN 30 DAYS.