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4 Easy Steps to place an order and speak with our Co-ordinator in 7 minutes
1. Complete your Order and Contact Information 2. Should you need help, call our co-ordinator at 866-989-0078. 3. For security reasons we do not take credit card information when you visit the site. 4. Submit the form and our Rep will get in touch with you for your payment information. 5. Your order will be shipped to you within the stipulated time.

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Your Order

Order Quantity	Product Code	Brand Name	Generic	Manufacturer	Content Per Unit	Total Units per Pkg	Price per Unit	Sub Total
	FO60	Follistim 600IU	FSH rec	Organon	Follistim 600IU	1 amp	$399	$399	Delete

	Order Total:		$399
	Shipping Charges:		$47
	Grand Total:		$446

Patient Information

Date:*

Name:*

Email:*

Phone:*

Ship To:*

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Physician Information

First and Last name:*

Clinic, IVF Center name:*

Phone:*

Fax:*

Address 1:*

Address 2:

City:*

State:*

Zip:*

The fields marked * are mandatory

By placing your order you accept our policy in conjunction with US Federal laws and EU laws that prohibit acceptance of returned medication. With your confirmation, you acknowledge acceptance of the laws and policy.

No order will be delivered without a valid physician prescription. Please email or fax your prescription.
By email: customercare@makemefertile.com By Fax: 212.202.6379 This form is not accepted unless duly signed.
Toll-Free Customer Service Hotline: 866.989.0078