babycells Kit Order Form

babycells ORDER FORM

UK CUSTOMER ONLY - PAYMENT VIA CHEQUE OR BANK TRANSFER

Mother's Details
First Name:
Last Name:
Address:


Post Code:
Country:	UNITED KINGDOM
Telephone:
Mobile:
Email:
Father's Details
First Name:
Last Name:
Telephone:
Mobile:
Email:

Other Details

Expected Date of Birth:
Birth Details:	Single Birth Twins Triplets
Hospital:
Consultant's Full Name:
Midwife's Full Name:
Source of Advertisement:
Additional Information:
Payment Method:	Bank Transfer Cheque
Payment Details:	Bank Transfer: If using bank transfer, please contact us for bank details. Cheque Payment: If paying by cheque, please make the cheque payable to Cells Limited and send it to the following address: Cells Limited Temple House 221-225 Station Road Harrow HA1 2TH United Kingdom
	I understand that the £195 including VAT (£390 for twins and £585 for triplets) paid for the collection kit(s) is non-refundable and that if the sample is not successfully stored I shall not be responsible for any further payments. I Agree