Order Form_PD1_FCPs Form PD1 FCPs
User Manual: OrderForm_PD1_FCPs
Open the PDF directly: View PDF 
.
Page Count: 2
CREIGHTON MODEL FertilityCareTM
PRACTITIONER PUBLICATIONS ORDER FORM (PD-1)
Order continues on Page 2 …
Order
Date
FCCA Center
Name
Name
FCCA
Center #
Phone #
Fax #
Purchase
Order#
BILL TO:
SHIP TO:
Name
Name
c/o
c/o
Address
Address
City/State
Zip
City/State
Zip
QUANTITY
ITEM
PACKAGE
PRICE
EXTENDED PRICE
Charts
Each
Package of 25
$ 1.50
$32.50
Spanish Charts
Each
Package of 25
$ 1.50
$32.50
User Manuals
Each
$ 10.00
Spanish User Manuals
Each
$10.00
Follow-up Forms
Each
Package of 25
$ 3.50
$81.25
Pregnancy Eval. - short
Each
$ 1.50
Pregnancy Eval. - long
Each
$ 2.00
Introductory Session
Power Point on CD
Each (Circle
MAC or PC)
$95.00
(Non returnable item)
General Intake Forms
Package of 25
$13.50
Information Cards
Package of 25
$12.00
Organizer Sheets
Pad of 25
$ 5.50
Spice Index Cards
Package of 25
$13.50
Telephone Pads
Pad of 25
$3.00
Introductory Session Evaluation
Pad of 25
$7.00
Follow-up Evaluation
Pad of 25
$7.00
Teacher Evaluation
Pad of 25
$7.00
Reproductive Category
Spec. Cycle Review
Pad of 25
$7.00
Census Form
Each
$ .35
Yellow Stamp Instructions Set
Individual YS Topic Package
Topic Name:_____________________
Set=1 each of
7 topics
25 sheets of
one topic
$3.00
$9.50
Picture Dictionary—Teacher Edition
1-4 ordered
5-9 ordered
10+ordered
$54.98 each
$49.98 each
$44.98 each
Picture Dictionary – User Edition
1
$20.00
4/8/14st Prices Subject to Change
Shipping and Handling, Discounts, Taxes, if applicable, will be applied.
All orders must be pre-paid before shipping. Estimate can be sent by email if paying by check.
Email address: _____________________________________________________________
Select Payment:
PayPal to account: publications@popepaulvi.com
Credit Card Number: _______________________________________________
Expiration Date: ____________________________
Name on card (please print) __________________________________________
Signature of Practitioner: ___________________________________________________
**ALL International orders will be required to pre-pay their invoices before shipping by credit card or PayPal to account:
publications@popepaulvi.com.
As of January 1, 2013, all domestic orders will be required to pre-pay before shipment. In order to be on a billing program, affiliated
FCCA centers and Educators will be required to sign a payment contract with Pope Paul VI Institute.
Return to:
Pope Paul Vi Institute
6901 Mercy Road
Omaha, NE 68106
Publications Email: publications@popepaulvi.com
Phone: 402-505-8942
FAX: 402-390-9851
QUANTITY
ITEM
PACKAGE
PRICE
EXTENDED PRICE
1 Stamp Starter Packs
11 sheets +
bag
$2.50
Protective Plastic
1 bag
$0.30
Plain Red Stamp
Per sheet
$0.25
White Baby Stamps
Per sheet
$0.25
Plain Green Stamps
Per sheet
$0.25
Green Baby Stamps
Per sheet
$0.25
Plain Yellow Stamps
Per sheet
$0.25
Yellow Baby Stamps
Per sheet
$0.25
Additional
Products:
TOTAL FOR MATERIALS ORDERED**
