www.ivfmeds.com
    
service@ivfmeds.com
 Worldwide  Fax: 44 20 7681 3255 North and Central America  Fax: (800) 258-4693    
Download an updated order form at: www.ivfmeds.com/orderform Required fields are in bold     
1) PATIENT INFORMATION:   2) MEDICAL INFORMATION:
Name:                                                   Prescribed by: Dr.                                                
Day Phone:                                                   Clinic Name:                                                
Evening Phone:                                                   Phone:                                                
Cell Phone:                                                   3) ORDERED BY: (only if you are not the patient)
Email address:                                                   Name:                                                
Date of birth:                                                   Day Phone:                                                
ID/SSN:                                                   Evening phone:                                                
      Cell phone:                                                
Expected start date     Email address:                                                
of the treatment:                                                   Relationship to Patient:                                                
4) SHIPPING INFORMATION:   5) BILLING INFORMATION:
Name:                                                          Billing address is the same as the shipping address
Company Name:                                                     
Address:                                                   Address:                                                
                                                                                                    
City:                                                   City:                                                
State:                       Zip:                     State:                       Zip:                  
Country:                                                   Country:                                                
Daytime Phone:                                                   Daytime Phone:                                                
6) CREDIT CARD INFORMATION:   7) SUBMITTED BY:
Credit Card: Visa     Name:                                                
Card number:                                                     
Card exp date:                  /                (mm/yy)   Signature:                                                
Name on card:                                                   8) PRESCRIPTION:

Signature:                                                          Is attached              Has already been faxed

** PLEASE REMEMBER TO FAX A COPY OF YOUR PRESCRIPTION **

IVFMeds.com is a referral service that enables fertility patients to purchase Brand European Pack IVF Medications from a Licensed European
Pharmacy (at the lowest prices we can find). Shipments can be arranged throughout the world. If you are looking for a Non-European pharmacy go
to: www.ivfmeds.com/noneuropharm All brands are registered trademarks of the manufacturers and of their affiliates in various countries. The
manufacturers do not participate in or sponsor our referral service. Physician's prescription is always required.

Download an updated order form at: www.ivfmeds.com/orderform

For Customer Service Call: www.ivfmeds.com    
North and Central America: (800) 341-0464, South America: 54 11 40 32 00 54     
Asia: 852 30 15 87 00, Europe: 33 1 53 01 33 31 / 44 20 7681 3003                        1-371 PAGE ONE    

 
 
  www.ivfmeds.com
    
service@ivfmeds.com
 Worldwide  Fax: 44 20 7681 3255 North and Central America  Fax: (800) 258-4693    

        Patient's Name: ___________________________ Order Date: ______________________    
Generic Name Brand Names Qty Price Total
Follitropin Alfa Gonal -F®
  Serono Europe Packaging Gonal -F® 75 IU              $42.00 $

  Serono Europe Packaging Gonal -F® 450 IU Multidose              $270.00 $

  Serono Europe Packaging Gonal -F® 1050 IU Multidose              $630.00 $

  Serono Europe Packaging Gonal -F® 900 IU Pen              $540.00 $

Gonal -F® is a reg'd trademark of Serono.

Follitropin Beta Follistim® / Puregon®

  Organon Europe Packaging Follistim® / Puregon® AQ 300 IU              $200.00 $

  Organon Europe Packaging Follistim® / Puregon® AQ 600 IU              $400.00 $

Follistim®, Follistim Pen®, Puregon® and Puregon Pen® are registered trademarks of Organon.

FSH/Urofollitropin Bravelle® / Fostimon®

  IBSA Europe Packaging Fostimon (Sub-Q) 75 IU              $30.00 $
Bravelle® is a reg'd trademark of Ferring and Fostimon® is a reg'd trademark of IBSA.

HMG Repronex® / Menopur® / Merional®

  Ferring Europe Packaging Menopur® (Sub-Q) 75 IU              $36.00 $

  IBSA Europe Packaging Merional (Sub-Q) 75 IU              $26.00 $

  Generic Europe Packaging Generic HMG (I/M) 75 IU              $14.50 $

Repronex® and Menopur® are trademarks of Ferring. Merional® is a trademark of IBSA.

HCG Pregnyl®
  Organon Europe Packaging Pregnyl® 10,000 IU              $30.00 $
Pregnyl® is a reg'd trademark of Organon, Profasi® is a reg'd trademark of Serono and Novarel® is a reg'd trademark of Ferring.

Leuproreline/ Leuprolide Lupron® / Enantone® / Procrin®

  Abbott Europe Packaging Procrin® 2 Wk Kit 5mg/ml - 2.8 ml              $171.00 $

  Takeda Europe Packaging Enantone® Depot 3.75 mg              $305.00 $

Lupron® is a reg'd trademark of TAP (Abbott and Takeda), Procrin® is a reg'd trademarks of Abbott, and Enantone® is a reg'd trademark of Takeda.

Ganirelix Antagon® / Orgalutran®

  Organon Europe Packaging Ganirelix 0.25 mg/0.5 ml              $64.00 $
Antagon® and Orgalutran® are registered trademarks of Organon.

Cetrorelix Cetrotide®
  Serono Europe Packaging Cetrotide® 0.25 mg              $66.00 $

  Serono Europe Packaging Cetrotide® 3 mg              $440.00 $

Cetrotide® is a registered trademark of Serono

Subtotal carried forward to page 3  $

 
All brands are registered trademarks of the manufacturers and of their affiliates in various countries. The manufacturers do not participate in or sponsor our referral service. Physician's
prescription is always required.
Download an updated order form at: www.ivfmeds.com/orderform
For Customer Service Call: www.ivfmeds.com    
North and Central America: (800) 341-0464, South America: 54 11 40 32 00 54     
Asia: 852 30 15 87 00, Europe: 33 1 53 01 33 31 / 44 20 7681 3003                        1-371 PAGE TWO    

 
 
  www.ivfmeds.com
    
service@ivfmeds.com
 Worldwide  Fax: 44 20 7681 3255 North and Central America  Fax: (800) 258-4693    

        Patient's Name: ___________________________ Order Date: ______________________    
Generic Name Brand Names Qty Price Total
Progesterone Suppos. Prometrium® / Cyclogest®
  Shire Europe Packaging (pack of 15) 200 mg              $32.00 $

  Shire Europe Packaging (pack of 15) 400 mg              $43.00 $

Cyclogest® is a reg'd trademark of Shire and Prometrium® is a reg'd trademark of Solvay.

Progesterone Capsules Prometrium® / Utrogestan®

  Ferring Europe Packaging (pack of 30) 100 mg              $25.00 $

  Ferring Europe Packaging (pack of 15) 200 mg              $25.00 $

Utrogestan® is a reg'd trademark of Ferring and Prometrium® is a reg'd trademark of Solvay.

Naferelin Acetate Spray Synarel®  
Pharmacia Synarel® 0.2 mg/0.5 ml              $190.00 $
Synarel® is a reg'd trademark of Pharmacia.

Progesterone 8% Gel Crinone®  
Serono Europe Pack Crinone® (15
             $110.00 $
apps) 8% Gel
Crinone® is a reg'd trademark of Serono.

Clomiphene Clomid® / Serophene®  

Aventis (price each tab) 50 mg              $1.50 $
Clomid® is a registered trademark of Aventis and Serophene® is a registered trademark of Serono.

Methylprednisolone Medrol® / Medrone®  

Pharmacia (price each) 16 mg              $2.10 $
Medrol® and Medrone® are registered trademarks of Pharmacia.

Doxycycline Caps Doxycycline  
Generic (price each cap) 100 mg              $1.00 $

Estradiol Vivelle® / Estraderm® / Estradot®

  Novartis Europe Packaging (8 dots) 0.1 mg              $25.00 $

  Novartis Europe Packaging (8 patches) 0.1 mg              $30.00 $

Vivelle®, Estraderm®, and Estradot® are registered trademarks of Novartis.

Estradiol Valerate Estrace® / Climaval®  

Novartis (pack of 28 tabs) 2 mg              $25.00 $
Estrace® and Climaval® are registered trademarks of Novartis.

Desogestrel Desogen® / Marvellon®  

Organon (pack of 63 tabs)              $30.00 $
Desogen® and Marvellon® are registered trademarks of Organon.

A Tracking number is emailed to you as soon as your   Calculate the Subtotal for this page: $

order is shipped by the pharmacy.  Speed Shipping takes
3-5 days, and Regular Shipping takes up to 10 days.  We   Subtotal from page 2: $
always recommend that you choose Speed Shipping if your
treatment is going to start in less than 2 weeks.   Calculate the Subtotal: $

Regular Shipping: $39.00 $
Please note that a signature is always required at the time       
of delivery.
  Speed Shipping:      $89.00 $
All brands are registered trademarks of the manufacturers and of their affiliates in various
countries. The manufacturers do not participate in or sponsor our referral service.   Calculate the Grand Total: $
 
 
** PLEASE REMEMBER TO FAX A COPY OF YOUR PRESCRIPTION **
 
For Customer Service Call: www.ivfmeds.com    
North and Central America: (800) 341-0464, South America: 54 11 40 32 00 54     
Asia: 852 30 15 87 00, Europe: 33 1 53 01 33 31 / 44 20 7681 3003                        1-371 PAGE THREE