Note: Currently we are only taking orders made with Money Orders.

Please fill out and print this entire order form.
If you do not have an email address, enter "none" in the email field.
Then send the printed out copy of it along with the order via snail mail to:

Judith Halek, Birth Balance
309 W. 109th St., Suite 6D
NYC, NY 10025.

Once printed, press the submit button to send an electronic copy of the order to us so we can be more prompt with your order.

An e-mail confirmation will be sent once the order and money order is received.

Name:
Email:
Address:
City:
State:
Country:
ZIP:
Phone:
Description of Video:
video code:
price $

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