Parent MAIL/FAX Order Packet

Perinatal Loss ~ Grief Watch

2116 NE 18th Ave. Portland, Oregon 97212 USA
PHONE: (503) 284-7426 FAX: (503) 282-8985

PARENT MAIL / FAX
ORDER FORM

Please print this order form for MAIL of FAX orders

PERSONAL INFO FORM

BILL TO:

Name:____________________________________

Address: __________________________________

City:________________ State:_________

Zip:___________________

Contact/Ordered By:__________________________

Phone:_______________________________

Email:____________________________________

SHIP TO:

Name:____________________________________

Address: __________________________________

City:________________ State:_________

Zip:_________________

Contact/Ordered By:__________________________

Phone:_______________________________

Email:________________________________

PAYMENT INFO:

Please Circle One: Credit Card 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_____

How Did You Hear About Perinatal Loss - Grief Watch?

Perinatal Loss ~ Grief Watch 2116 NE 18^th Ave Portland, Oregon 97212 Phone: 503-284-7426 FAX 503-282-8985		Parent Order Form (Please also complete and include the Personal Information Form with your order)
QTY	ITEM - description	color / size / style	Price Each	Total
	Tear Soup- a recipe for healing after loss		$ 19. 95
	When Hello Means Goodbye - English		$ 3. 00
	Cuando Hola Significa Adios - WHMG Spanish		$ 3. 00
	Strong and Tender		$ 3. 00
	Too Soon a Memory		$ 3. 00
	Una Memoria Demasiado Temprana - TSAM Spanish		$ 3. 00
	A Grandparent’s Sorrow		$ 3. 00
	Still To Be Born		$ 6. 00
	Momma (audiotape and book)		$ 12. 50
	From Sorrow to Serenity		$ 9. 25
	Our Stories of Miscarriage-		$ 13. 95
	Certificate of Life Hand Calligraphy	Mis. Still. Neo.	$ 8. 75
	Remembering Heart		$ 5. 50 in a box $ 5. 00 in a bag
	The Heart Within		$ 4. 00
	The Love Stone	(minimum order 10)	$ 1. 00 ea.
	Feeling Hearts w/ drawstring bag		$ 17.50
	Angel in a Pocket	W T A	$ 4. 00
	Angel Ornament		$ 2. 00
	The Rainbow Butterfly		$ 3. 50
	Comfee	purple blue red multi	$ 8. 00
	Personalized Birth Announcements Please Complete Attached Card Order Form	Minimum order 2 packs. (10) cards per pack.	$ 15. 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 - For the Love of Our Family		$ 89. 95
	Video - But I Didn’t Surrender My Love		$ 35. 00
	T - Shirt - "some people dream of angels..."	M L XL XXL	$ 15. 00
			SUBTOTAL
NOTES / Special Requests			SHIPPING
NOTES / Special Requests			TOTAL

Birth Announcements Mail / Fax Order Form
(Please also complete and include the Personal Information Form with your order)

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

NAME:

Standard Announcements

# OF CARD PACKS YOU WANT TO ORDER: ______ (10 cards per package $7.50 each)

Circle choice of message for front of card: a b c d e

Our child is a: GIRL BOY Our child died through: Miscarriage Stillborn Neonatal death

____ Check here if you are a single parent and want singular pronouns on cards

Personalized Birth Announcements

# OF CARD PACKS YOU WANT TO ORDER: _______ (10 cards per package $15. 00 each )

Our child is a: GIRL BOY Our child died through: Miscarriage Stillborn Neonatal death

____ Check here if you are a single parent and want singular pronouns on cards

Front of announcement: Circle your choice of message for front of card: a b c d e f g h i j k

Or in the space provided below print your own message exactly as you want it to appear on the front of the card:

Inside of announcement: Using suggestions L through R ( on Card Example Sheet ), or developing your own, please print in the space below the words which you would like to have printed inside the card:

Do you want the "Message to Friends" printed on the back of your cards? (no charge) YES NO

Would you like your return address printed on the back of your envelopes? (no charge) YES NO

CARD EXAMPLES: The following are sample verses. You may choose one, combine phrases, or create your own. Please call us if you have questions or need more suggestions.
Front of Birth Announcement Examples A person’s a person no matter how small." B. "Hold close these moments for we shall always live by remembering." C. "Unto us a child is born, a special child for a special reason. We don’t pretend to understand, only to accept and to love." D. "In an instant you touched our (my) heart(s) forever." E. "Our joys will be greater, our love will be deeper, our lives will be fuller, because we shared (his, her, their moment(s)." F. "She (he) is precious in the eyes of God." G. "And in a twinkling of an eye this little one came into our (my) heart(s)." H. "Our (my) dreams are sure gonna miss him (her)." I. "Some people only dream of angels. We (I) held one in our (my) arms." J. "An angel sent from heaven returned to heaven." K. Your own message * only available in Personalized cards
Inside of Personalized Card: L. Our baby (name) was born on (date) and died on (date). Even though she was with us for only a short time, we loved her very much. (parents’ names) M. (Parents’ names) sadly announce the birth and death of their son (name) on (date and time). (weight and length). We will love him always. N. Our baby (name) was silently born on (date and time). He will be sadly missed by his brother (name),his sisters (names), and his parents (names). O. We are sad to announce the short life of our daughter, (name). She came and went in an instant on (date), taking with her a lifetime of hopes and dreams we had for her. We will hold her in our hearts forever. (parents’ names) P. Our baby girls, (names), were silently born on (date). We will miss the warmth of their touch, the chorus of their voices, and the patter of their feet. But their love will live forever. (parents’ names) Q. Because we know you care about us, we want you to know that on (date), our wished-for baby passed quickly through our lives. We are saddened, but remain hopeful that someday soon our desire to have a child will be fulfilled. (parents’ names) R. Our twins, (names), were born on (date). (Name) died shortly after birth. We are happy to report that her sister (name) is gaining weight and will be coming home soon. (Name) will always be remembered by her (twin sister, parents).
Back of card "Message to Friends" The following message is optional on the back of personalizedannouncements. Dear Family and Friends, Acknowledgment of our baby’s short life may be upsetting to you. You may think the less said, the better. Until now, we did not know how important it would be for us to tell you of our baby even though our baby died. You can help us through this difficult time by letting us talk about our sorrow when we feel the need, allowing us to cry when we want, and not pretending everything’s okay....when it’s not. It will take time, but with your support we will make it.	* NOTE:* Announcements are printed on 100 lb white cardstock. Requests are accepted for additional cardstocks and are handled on a per order basis. There is a additional charge for a custom cardstock. Please call our office for more information.

Certificate of Life Mail / Fax Order Form

(Please also complete and include the Personal Information Form with your order)

Please note that this form is used for several types of Certificates. Please complete only the information that applies to your type of loss and order, skip the questions that do not apply. Thank you.

NAME:

Type of Certificate Circle One: Miscarriage Stillborn Neonatal

Child’s Full Name: __________________________________________________

Parents’ Name(s):___________________________________________________________

Hospital Name:__________________________________________

City:____________________________ State: ________________________________

Date of Birth: _____________________________ Time:__________________ AM PM

Date of Death:____________________________ Time:__________________ AM PM

Weight:___________________________ Length:___________________ Month of Conception:____________

Doctor:_____________________________________ Nurse(s): ____________________________________

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

Amount of Order	Shipping
$ 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

• Returns are subject to a 20% restocking fee * Canada orders please call for shipping info 503-284-7426

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