Professional Documents
Culture Documents
www.ivfmeds.com
service@ivfmeds.com
Worldwide Fax: 44 20 7681 3255 North and Central America Fax: (800) 258-4693
Download an updated order form at: www.ivfmeds.com/orderform Required fields are in bold
1) PATIENT INFORMATION: 2) MEDICAL INFORMATION:
Name: Prescribed by: Dr.
Day Phone: Clinic Name:
Evening Phone: Phone:
Cell Phone: 3) ORDERED BY: (only if you are not the patient)
Email address: Name:
Date of birth: Day Phone:
ID/SSN: Evening phone:
Cell phone:
Expected start date Email address:
of the treatment: Relationship to Patient:
4) SHIPPING INFORMATION: 5) BILLING INFORMATION:
Name: Billing address is the same as the shipping address
Company Name:
Address: Address:
City: City:
State: Zip: State: Zip:
Country: Country:
Daytime Phone: Daytime Phone:
6) CREDIT CARD INFORMATION: 7) SUBMITTED BY:
Credit Card: Visa Name:
Card number:
Card exp date: / (mm/yy) Signature:
Name on card: 8) PRESCRIPTION:
www.ivfmeds.com
service@ivfmeds.com
Worldwide Fax: 44 20 7681 3255 North and Central America Fax: (800) 258-4693
Patient's Name: ___________________________ Order Date: ______________________
Generic Name Brand Names Qty Price Total
Follitropin Alfa Gonal -F®
Serono Europe Packaging Gonal -F® 75 IU $42.00 $
HCG Pregnyl®
Organon Europe Packaging Pregnyl® 10,000 IU $30.00 $
Pregnyl® is a reg'd trademark of Organon, Profasi® is a reg'd trademark of Serono and Novarel® is a reg'd trademark of Ferring.
Cetrorelix Cetrotide®
Serono Europe Packaging Cetrotide® 0.25 mg $66.00 $
Subtotal carried forward to page 3 $
All brands are registered trademarks of the manufacturers and of their affiliates in various countries. The manufacturers do not participate in or sponsor our referral service. Physician's
prescription is always required.
Download an updated order form at: www.ivfmeds.com/orderform
For Customer Service Call: www.ivfmeds.com
North and Central America: (800) 341-0464, South America: 54 11 40 32 00 54
Asia: 852 30 15 87 00, Europe: 33 1 53 01 33 31 / 44 20 7681 3003 1-371 PAGE TWO
www.ivfmeds.com
service@ivfmeds.com
Worldwide Fax: 44 20 7681 3255 North and Central America Fax: (800) 258-4693
Patient's Name: ___________________________ Order Date: ______________________
Generic Name Brand Names Qty Price Total
Progesterone Suppos. Prometrium® / Cyclogest®
Shire Europe Packaging (pack of 15) 200 mg $32.00 $
Naferelin Acetate Spray Synarel®
Pharmacia Synarel® 0.2 mg/0.5 ml $190.00 $
Synarel® is a reg'd trademark of Pharmacia.
Progesterone 8% Gel Crinone®
Serono Europe Pack Crinone® (15
$110.00 $
apps) 8% Gel
Crinone® is a reg'd trademark of Serono.
Doxycycline Caps Doxycycline
Generic (price each cap) 100 mg $1.00 $
Regular Shipping: $39.00 $
Please note that a signature is always required at the time
of delivery.
Speed Shipping: $89.00 $
All brands are registered trademarks of the manufacturers and of their affiliates in various
countries. The manufacturers do not participate in or sponsor our referral service. Calculate the Grand Total: $
** PLEASE REMEMBER TO FAX A COPY OF YOUR PRESCRIPTION **
For Customer Service Call: www.ivfmeds.com
North and Central America: (800) 341-0464, South America: 54 11 40 32 00 54
Asia: 852 30 15 87 00, Europe: 33 1 53 01 33 31 / 44 20 7681 3003 1-371 PAGE THREE