Meal Replacement Order Form



Name:
Telephone Number:
Date:

Method of Payment:

Please indicate only the method of payment. As this is not a secure site,
do not enter any charge or account information. We will collect that
information when the product is picked up.

Cash
Check
Visa
Master Card
Discover Card


You may place your order in 3 ways:
1. Call 419-251-8760 to place your order by phone
2. Print and fax the completed form to 419-251-8765
3. Submit online by completing the form below and select "submit".

Orders will be available for pick-up in 24 hours at the
Mercy Weight Management Center
3930 Sunforest Ct. Suite 100
Toledo, OH 43623
during business hours.

HMR Shakes & Soup

HMR 800
C
V
Qty Qty
HMR 70 Plus
C
V
Qty Qty
HMR 120
C
V
Qty Qty
HMR 500 Chicken Soup

Qty

HMR Entrees

BBQ Chicken w/rice & Beans Chicken Pasta Parmesan Mac & Cheese with Butternut Squash Savory Chicken Chicken Enchiladas with Tomatillo Sauce
Qty Qty Qty Qty Qty
Veg Stew w/beef Turkey Chili Lasagna w/meat Sauce Whole Grain Medley with Chicken Cheese & Basil Ravioli Mushroom Risotto
Qty Qty Qty Qty Qty Qty
Beef
Stroganoff
Penne Pasta with Meatballs in Sauce Pasta Fagioli Rotini Chicken Alfredo Lentil Stew
Qty Qty Qty Qty Qty

Benefit Bars

Peanut Butter Iced Oatmeal Lemon Chocolate Chocolate
Qty Qty Qty Qty

Cereal

Multigrain Cereal Boxes
Qty


Powdered Peanut Butter

PB2
Qty