Femcap ::: A New Non-Hormonal Latex-Free Birth Control Method for Health-Conscious Women

1) One single FemCap and the instructional videotape:	$73.95
This includes shipping & handling
with DVD	$79.95

2) A kit containing Two FemCaps and the instructional videotape:	$94.95
This includes shipping & handling
with DVD	$97.95

Client and Billing Information Fields in red are required
	I have read the information above and understand the terms.
Obstetrical History:	Never Been Pregnant ( 22mm )
	Been Pregnant but miscarried or delivered by Cesarean Section- never delivered vaginally (26mm)
	Delivered a full-term baby30mm
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Health Care Provider Information and Prescriptions are required by the FDA.
First Name Provider:
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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.
FemCap Order:	One FemCap with VHS One FemCap with DVD Two FemCaps with VHS Two FemCaps with DVD