babycells Twin Kit Order Form

babycells ORDER FORM

UK CUSTOMER ONLY - PAYMENT VIA CREDIT or DEBIT CARD

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:

Hospital:
Consultant's Full Name:
Midwife's Full Name:
Source of Advertisement:
Additional Information:

Payment Details:	You will be taken to the payment system after you press submit. We accept the following credit or debit cards.
	I understand that the £250 including VAT (2 collection kits for twins) paid for the collection kits is non-refundable and that if the sample is not successfully stored I shall not be responsible for any further payments. I Agree