Order Form - medifastmedia.com

1 Step Three: Enter your billing information On Card _____ Phone _____ Address _____City _____ State _____ Zip _____ Step Four: Enter your credit card information below. (Sorry, no checks or CODs. Don t forget to sign and date below.) Visa q MC q Amex q Disc qCredit Card No. _____ Exp. Date _____ Security Code _____Signature _____ Date _____Step Five: Call in orders to (800) 572-4417 OR Fax orders to (443) 471-3319 Prices subject to #Product DescriptionPriceQTYOPTAVIA Select Kits76955 OPTAVIA Select Optimal Kit with the Habits of Health System$ Select Favorites Kit$ #Product DescriptionPriceQTYOPTAVIA Essential KitsIndexing 100%76961 OPTAVIA Essential Optimal Kit with the Habits of Health System$ Essential Optimal Kit$ Essential On-The-Go Kit with the Habits of Health System$ Essential On-The-Go Kit$ #Product DescriptionPriceQTYOPTAVIA Materials50011 OPTAVIA Fuelings Information Cards$ Fuelings Guide (pack of 10)

2 $ 30 Guide$ #Product DescriptionPriceQTYOPTAVIA Select Fuelings - 7 servings/boxIndexing 100%Bars - 7 servings/box 65957 Chocolate Cherry Ganache Bar with Dried Cherries, Pomegranate, and Chia Seeds, Naturally Flavored$ Chili Cranberry Nut Bar with Flaxseeds, Pumpkin Seeds, and Almonds, Naturally Flavored$ Chocolate Coconut Curry Bar with Almonds and Sea Salt, Naturally Flavored$ & Smoothies - 7 servings/box 71250 Chia Bliss Smoothiewith Coconut Sugar from the Philippines, Kiwi, Pineapple, Blueberry, and Apple$ Chocolate Covered Cherry Shakewith Real Cocoa, Naturally Flavored$ Renewal Shakewith Kale, Spinach, Spirulina, Carrot, Banana, Apple, Lemon, and Ginger$ Choices - 7 servings/box 53500 Buttermilk Cheddar Herb Biscuitwith Mediterranean Rosemary and Moroccan Thyme$ Mac & Cheese with Aged, Sharp Cheddar$ Pesto Mac & Cheesewith Basil and a Blend of Parmesan and Romano Cheeses$ Sweet Potatoeswith Brown Sugar and Indonesian Cinnamon$ Style - 7 servings/box 68350 Wild Blueberry Almond Hot Cerealwith Chia Seeds from Bolivia and Supergrains$ Cinnamon and Honey Hot Cereal with Chia Seeds from Bolivia, Quinoa.

3 And Whole Grain Barley$ Style - 7 servings/box 53550 Cinnamon Cream Cheese Swirl Cakewith Indonesian Cinnamon, Naturally Flavored$ #Product DescriptionPriceQTYOPTAVIA Essential Fuelings - 7 servings/boxIndexing 100%Bars - 7 servings/box 77895 Campfire S mores Crisp Bar - Naturally Flavored$ Delight Crisp Bar - Naturally Flavored$ Mint Cookie Crisp Bar - Naturally Flavored$ Honey Nut Granola Bar - Naturally Flavored$ Chocolate Fudge Crisp Bar - Naturally Flavored$ Cinnamon Spice Crisp Bar - Naturally Flavored$ Cookie Dough Bar - Naturally Flavored$ Oat Cinnamon Crisp Bar - Naturally Flavored$ Peanut Butter and Chocolate Chip Bar - Naturally Flavored$ & Smoothies - 7 servings/box

4 77815 Creamy Chocolate Shake - Naturally Flavored$ Vanilla Shake - Naturally Flavored$ Strawberry Shake - Naturally Flavored$ Choices - 7 servings/box 77860 Roasted Garlic Creamy Smashed Potatoes - Naturally Flavored$ Cream & Chive Smashed Potatoes - Naturally Flavored$ Tomato Herb Penne - Naturally Flavored$ Style - 7 servings/box 77840 Golden Chocolate Chip Pancakes - Naturally Flavored$ Pancakes - Naturally Flavored$ Fashioned Maple & Brown Sugar Oatmeal - Naturally Flavored$ Apple & Cinnamon Spiced Oatmeal - Naturally Flavored$ Style - 7 servings/box 77850 Decadent Double Chocolate Brownie - Naturally Flavored$ !

5 NEW!NEW!Item #Product DescriptionPriceQTYOPTAVIA Accessories50015 OPTAVIA Blender Bottle Classic $ FormStep One: Enter your shipping address and contact information Name Client ID # Address City State Zip Phone # Email Health Coach ID #Referred By (Client name and ID #) 11445 Cronhill Drive, Owings Mills, MD 21117 Client wants to enroll in BeSlim Club Client Declines BeSlim Club offer Client already BeSlim Club MemberStep Two: Enter your Order belowSubtotal from this pageSHIPPING: All non-expedited orders ship standard ground rates through a common carrier.

6 Receive reduced or free shipping on every BeSlim Club Order over $150 within the continental * Please note: For non-BeSlim Club orders, expedited shipping is at full cost, regardless of Order total. *To be an active BeSlim Club member and receive all benefits, an Order is required to be placed every 60 days. See BeSlim Club Terms and Conditions for full TOTALSUBTOTAL _____- COUPON _____+ SHIPPING _____TOTAL _____TS-0406-FRM_OrderForm_030617 Step Two: Enter your Order belowOrder FormStep One: Enter your shipping address and contact information Name Client ID # Address City State Zip Phone # Email Health Coach ID #Referred By (Client name and ID #) Item #Product DescriptionPriceQTYS hakes - 7 servings/box52550 Dutch Chocolate Shake$ Vanilla Shake$ Shake$ Cream Shake$ Shake$ Shakes (whey-based) - 7 servings/box72670 Dark Chocolate Antioxidant Shake$ Shakes - Singles68700 Dutch Chocolate Ready-to-Drink Shake$ Vanilla Ready-to-Drink Shake$ Ready-to-Drink Shake$ Shakes - Cases (24 singles/case)

7 68700 Dutch Chocolate Shake Ready-to-Drink Shake$ Vanilla Shake Ready-to-Drink Shake$ Shake Ready-to-Drink Shake$ - 7 servings/box72870 Triple Berry Smoothie$ Mango Smoothie$ Drinks - 7 servings/box57300 Hot Cocoa$ Burn Cappuccino$ - 7 servings/box66570 Cranberry Mango Fruit Drink$ Choices - 7 servings/box66590 Hearty Vegetarian Sloppy Joe$ & Cheese$ Cream & Chive Mashed Potatoes$ Mashed Potatoes$ Marinara$ Chili$ - 7 servings/box57400 Chocolate Pudding$ Cronhill Drive, Owings Mills, MD 21117 Client wants to enroll in BeSlim Club Client Declines BeSlim Club offer Client already BeSlim Club MemberItem #Product DescriptionPriceQTYBars - 7 servings/boxCrunch Bars 64905 Chocolate Mint Crunch Bar$ Butter Crunch Bar$ Crunch Bar$ Raisin Crunch Bar$ Crunch Bar$ more Crunch Bar$ Crunch Bar$ Roll Crunch Bar$ & Nut Crunch Bar$ Meringue Crunch Bar$ Bars 65556 Cookie Dough Chewy Bar$ Butter Chocolate Chip Chewy Bar$ Bar (limit to one per day on the 5 & 1 Plan )

8 65440 Caramel Nut Maintenance Bar$ - 7 servings/box69660 Beef Vegetable Soup$ Rice & Chicken Flavored Soup$ Flavored Noodle Soup$ Basil Bisque Soup$ - 7 servings/box58000 Apple Cinnamon Oatmeal$ Oatmeal$ & Brown Sugar Oatmeal$ Flavored Oatmeal$ - 7 servings/box57700 Original Pancakes$ Chip Pancakes$ Pancakes$ Bakes - 7 servings/box57530 Gingerbread Soft Bake$ Soft Bake$ Chip Soft Bake$ Muffin Soft Bake$ Serve - 7 servings/box57620 Chocolate Mint Soft Serve$ Soft Serve$ Soft Serve$ Crunch - 7 servings/box68400 Cinnamon & Brown Sugar Cereal Crunch$ Berry Cereal Crunch$ from this pageItem #Product DescriptionPriceQTYO ptimal Medifast Classic Health Kit (4 Weeks)74781 BeSlim Optimal Health 3&3 Kit$ Optimal Health 3&3 Kit$ #Product DescriptionPriceQTYBeSlim Club Exclusive Offers (Offered only for BeSlim Club orders above $310.)

9 These exclusive offers are non-returnable.)74881Dr. A s Habits of Health Bundle* (25% Off)$ 76967 OPTAVIA Select Shake Pack (42% Off)$ 76968 OPTAVIA Select Breakfast Pack (42% Off)$ Select Bar Pack (42% Off)$ !NEW!NEW!Prices subject to : All non-expedited orders ship standard ground rates through a common carrier. Receive reduced or free shipping on every BeSlim Club Order over $150 within the continental * Please note: For non-BeSlim Club orders, expedited shipping is at full cost, regardless of Order total. *To be an active BeSlim Club member and receive all benefits, an Order is required to be placed every 60 days.

10 See BeSlim Club Terms and Conditions for full TOTALSUBTOTAL _____- COUPON _____+ SHIPPING _____TOTAL _____Item #Product DescriptionPriceQTYC runchers - 7 servings/boxPretzel Sticks 68250 Cinnamon Pretzel Sticks$ Mustard Pretzel Sticks$ Bites$ Pizza Bites$ Puffs67245 Chili Nacho Cheese Puffs$ Cheese Puffs$ Health by Take Shape For Life - 7 servings/box65561 Dark Chocolate Dream Bar$ Caramel Nut Bar$ Yogurt Bar$ Peanut Butter Shake$ & Cream Shake$ a Colada Smoothie$ Banana Smoothie$ of Home Meals66665 Chili Lime Chicken$ Lemongrass Chicken$ Meatball Marinara$ with Rice & Vegetables$ Cacciatore$ Stew$ - 7 servings/boxPopcorn - These are not Take Shape For Life Salt Popcorn$ & Sour Cream Popcorn$ Crisps - These are not Take Shape For Life Cinnamon Crisps$ Crisps$ & Olive Oil Crisps$ - These are not Take Shape For Life Crackers$ Sea Salt Crackers$ of Healthy Sleep - On Sale!