Order Form

Please complete the following information, print and fax this page to 240-465-0866. Or you may call us at 301-593-8333.

Which Program Would You Like To Order?*: Deep Relaxation For Childbirth ($18)

General Relaxation ($5) Weight Loss Relaxation Metaphor ($5) Weight Loss Restaurant Exercise ($5)


First Name*:xxxi Last Name*:

Billing Address*:

Billing Address:

City*:xxxxxxxxix

State*:xxxxxxxxi

Zip*:xxxxxxxxxx

Phone*: xxxxxx( ) -

E-mail*: If Deep Relaxation For Childbirth, when is the baby due?


If Deep Relaxation For Childbirth is a gift, check here and enter shipping information below (if different from above). If this is not a gift, leave checkbox blank but fill in shipping information below.

Recipient's Name:

Mailing Address:ii

Mailing Address:ii

City:xxxxxxxxxxix

State:xxxxxxxxxxi

Zip:xxxxxxxxxxxx


How would you like to pay?

Credit Card*: Visa Mastercard American Express Discover

Name (as it appears on card)*:

Card Number (no spaces or dashes)*: Expiration Date (mm/yy)*: (example: 01/03)

If American Express, the 4 digit security code printed on the front of your card (small font, not embossed):

PRINT THIS FORM AND FAX TO 240-465-0866.

*Required field.

Your credit card will be billed by Centers For Motivation/CFM. For International orders, add $7.50 US onto shipping charges.