Order Form for Birthing With Hypnosis Products
Please Fax to: 212-362-5762 All orders will be confirmed within 24 hours by telephone:


Please provide us with your Telephone Number:__________________________

or Email address:________________________________for confirmation.


Name:_______________________________

Address for Shipping:___________________________________________________________

City __________________________ State:________________ Zip Code__________________

Due Date:____________________

How did you Hear about Us:____________________________________________________


Credit Card Information:

Name as it is Exactly Written on the Credit Card__________________________

Amex:______________________________Exp.Date:__________

3 Digit Code on Reverse Side______

Visa/MC:______________________________Exp.Date:__________

3 Digit Code on Reverse Side______


Billing Address if Different from Mailing Address: ______________________________________

City __________________________ State:________________ Zip Code__________________


Please check product and Shipping Preferences:

Home Study Program: Cost: $175.00 Plus Rush Shipping Fee by Fed Express: $30.00

US Mail 3 to 5 Business days: $9:00_______

Handling Fee: $7.00________

Total: _______

Books:Please indicate Title__________________________________Cost:_______________

Postage & Handling: $6.00______________

Rush Delivery: Fed Exp: $15.00__________

Total:________

You will receive a receive a receipt and shipping confirmation by email or phone within 24 hours of receipt of your order. You may also contact us by phone 646-519-1076 or email: hypnobirthingnyc@aol.com or fax: 212-362-5762