Professional MAIL / FAX Order Form

Perinatal Loss ~ Grief Watch	GENERAL ORDER FORM
Please print this order form for MAIL of FAX orders
2116 NE 18th Ave. Portland, Oregon 97212 PHONE:(503) 284-7426 FAX: (503) 282-8985
BILL TO: Name/Company:______________________________ Attn:______________________________________ Address: __________________________________ City:________________ State:_________ Zip:___________________ Contact/Ordered By:__________________________ Phone:_______________________________ Email:____________________________________	SHIP TO: Name/Company:______________________________ Attn:______________________________________ Address: __________________________________ City:________________ State:_________ Zip:___________ Contact/Ordered By:__________________________ Phone:_______________________________ Email:________________________________
PAYMENT INFO: Purchase Order #:__________________ Please Circle One: Bill US Check Enclosed	Credit Card: Visa or MasterCard Only Please Circle One: VISA Master Card Card # _____________________________ EXP Date:______/______
Would you like to Join our Mailing List: YES_____ NO_____

Product List
NAME/COMPANY:
QTY	ITEM - description	color / size / style	Price Each	Total
	Tear Soup- a recipe for healing after loss		$ 19. 95
	When Hello Means Goodbye - English Cuando Hola Significa Adios -WHMG Spanish Strong and Tender A Grandparent’s Sorrow Too Soon a Memory		1 - 24 $ 3. 00 25 - 49 $ 2. 70 50 - 149 $ 2. 55 150 + $ 2. 25




	Still To Be Born		1 - 24 $ 6. 00 25 - 49 $ 5. 40 50 - 99 $ 5. 10 100 + $ 4. 50
	Momma (audiotape and book)		$ 12. 50
	From Sorrow to Serenity		$ 9. 25
	Our Stories of Miscarriage-		$ 13. 95
	Certificate of Life (blank)	miscarriage, stillborn, neonatal	1 - 24 $ 3. 50 25 + $ 3. 00
	Remembering Heart		1 - 24 $ 5. 00 25 - 49 $ 4. 75 50 + $ 4. 50
	The Heart Within		1 - 9 $ 4. 00 10 + $ 3. 50
	The Love Stone	min order 10 stones	1 - 24 $ 1. 00 ea. 25 + $ . 75 ea.
	Feeling Hearts w/ drawstring bag		$ 17.50
	Angel in a Pocket	W T A	1 - 24 $ 4. 00 25 + $ 3. 50
	Angel Ornament		$ 2. 00
	The Rainbow Butterfly		$ 3. 50
	Support Cards - cards for leaders and groups		$ 5. 00
	Caring Cards	a b c d e f g h i j k	$ 9. 50
	Memory Album - Spiral Bound		$ 15. 00
	Memory Album - DELUXE		$ 30. 95
	Video - Still To Be Born		$100. 00
	Video - Momma		$ 29. 95
	Video - For the Love of Our Family		$ 89. 95
	Video - But I Didn’t Surrender My Love		$ 35. 00
	Free Catalogues For Parents N.C.			NC
			SUBTOTAL
NOTES / Special Requests			SHIPPING
			TOTAL

Professional Certificate of Life Mail / Fax Order Form

(Please also complete and include the Professional General Order Form with your order)

These Certificates are available with blank fields; ready for you to fill out and present to your patient while they are still in your care. To learn more about the Certificate of life VISIT HERE.

NAME / COMPANY

Type of Certificate Circle One: Miscarriage Stillborn Neonatal

COST:
1 - 24 Certificates $ 3. 50 ea.
25 + Certificates $ 3. 00 ea.

	Miscarriage	Still Born	Neonatal	Cost Each	TOTAL
# OF Certificates				$
				SUBTOTAL	$
				SHIPPING	$
				TOTAL	$

Grief Watch 2116 NE 18^th Ave Portland, Oregon 97212 Phone: 503-284-7426 FAX 503-282-8985

Professional Caring Card Mail / Fax Order Form
(Please also complete the Professional Info & Product Order Form)

Organization:

NAME:

Professional Caring Cards

# OF CARD PACKS YOU WANT TO ORDER: ______ (10 cards per package $9.50 each. Min order 2 packs)

Please circle the style of cards you would like: a b c d e f g h I j k
(see attached example sheet for card examples)

For multiple pack orders please indicate the quantity of each style you would like below:

____A ____B ____C ____D ____E ____F ____G ____H ____I ____J ____K

* minimum order (2) card packs

Customized Caring Cards:

# OF CARD PACKS YOU WANT TO ORDER: _______ (10 cards per package $15. 00 each )
Minimum order on customized caring cards is (4) packs

Please use the space provided below print your own message exactly as you want it to appear on
the FRONT of the card:

Please use the space provided below print your own message exactly as you want it to appear on
the INSIDE of the card:

Would you like your return address printed on the back of your envelopes (no charge) ____YES ____NO

* Minimum order on customized caring cards is (4) packs

Amount Of Order	Shipping Cost
$ 1. 00 - 10. 00	$ 4. 00
10. 01 - 20. 00	4. 75
20. 01 - 30. 00	6. 50
30. 01 - 40. 00	7. 00
40. 01 - 60. 00	8. 50
60. 01 - 80. 00	9. 50
80. 01 - 100. 00	10. 00
100. 01 - 125. 00	11. 00
125. 01 - 150. 00	12. 50
150. 01 - 175. 00	13. 00
175. 01 - 200. 00	14. 00
200. 01 - 250. 00	15. 00
250. 01 - 300. 00	15. 50
300. 01 - 350. 00	17. 50
350. 01 - 400. 00	22. 00
400. 01 - 450. 00	23. 00
450. 01 - 500. 00	24. 00
Over 500. 01 (+) please call our office at 503-284-7426
All Orders Shipped Via UPS Ground

Postage Chart