Payment by Fax or Mail
OR, click here to order online

1. Fill out the form below and print 2. Mail or fax the form with credit card payment or check to the address or fax on the right. Make check payable to Pacifeeder. (we accept checks and money orders only).

Mailing Address: Pacifeeder 21520 Yorba Linda Blvd., Suite G-458 Yorba Linda, CA 92887 Fax form to: 714-692-0182

Pacifeeder® Order Form

First Name: Last Name: Street Address: City: State/Province: Postal Code: Country: Where did you hear about us? Infoseek Alta Vista Webcrawler HotBot Excite Lycos TV Home & Family Show Magazine Friend Family New York Times Magazine Twins Magazine Working Mother Magazine American Baby Magazine Parenting Magazine Baby Talk Magazine Parents Magazine Child Magazine Other:

Daytime Phone: Fax Number: E-mail Address: Credit Card VISA MasterCard Discover AMEX Credit Card Number: Expiration Date:

Pacifeeder  Quantity  Description  Unit Price    Pink Stars Pacifeeder  $19.99    Blue Fish Pacifeeder  $19.99    Yellow Dinosaur Pacifeeder  $19.99 Shipping: Add $6.50 for shipping & handling for 1 bottle. Add $1 for each additional bottle. Product will ship by USPS Priority Mail. Please allow 3-5 business days for delivery.

Replacement Parts Description Qty Price Blue Nipple Yellow Nipple Pink Nipple 3.00 Adapter 5.50 Long Tube 1.00 Flexi-Tube .80 Blue Bottle & Cap Pink Bottle & Cap Yellow Bottle & Cap 3.70 Blue Cap Pink Cap Yellow Cap .30 Flushing Disk .75 Washer .40 Short Tube .80 Smart Grip Velcro® Strap 4.00 Cleaning Brush 2.00 Subtotal: Add 7.75% CA Tax (CA orders only) Shipping Charges $6.50 ea. TOTAL