2)
A kit containing Two FemCaps and the instructional DVD:
$108.00
Plus
shipping & handling
$8.95
total:
$116.95
I have read
the information above and understand the terms.
Obstetrical History:
( 22mm )
(26mm)
Delivered a full-term baby30mm
Client
and Billing Information
Fields
in red are required
First Name:
Last Name:
Address 1:
Address 2:
City:
State:
Country:
Zipcode:
Telephone Number:
Email Address:
Business Name:
Health
Care Provider Information and Prescriptions are required by the FDA.
First Name Provider:
Last Name Provider:
Address Provider:
City Provider:
State Provider:
Country Provider:
Zipcode Provider:
Telephone Provider:
Please mail this form and your check payable to FemCap, Inc., 14058
Mira Montana Drive, Del Mar, CA 92014. Once the prescription has been
received and your check has cleared, FemCap will mail your order
via priority mail with delivery confirmation.
