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	Creamy Mac & Cheese	Chicken Enchiladas with Tomatillo Sauce
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	Fiesta Chicken	Crustless Chicken Pot Pie	Sausage & Potato in Gravy
Qty	Qty	Qty	Qty	Qty	Qty	Qty

Benefit Bars

Peanut Butter	Iced Oatmeal	Lemon	Chocolate Chocolate	Fruit & Nut Bar	Fudge Graham Bar
Qty	Qty	Qty	Qty	Qty	Qty

Cereal

Multigrain Cereal Boxes