PLEASE COMPLETE THIS ORDER FORM AND WE WILL CONTACT YOU FOR YOUR PAYMENT DETAILS

   I would like to order 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 product Please select a pillow Standard Silver Lining HC01 £18.99 incl of UK P&P Replacement Airbag HC02 £5.25 incl UK P & P Ortho V Shaped anti-mite HC03 £35.00 incl UK P&P Neckcare anti-mite HC05 £30.00 incl UK P&P Fibre anti-mite pillow firm HC06 £29.00 incl UKP&P

                                     Title Mr Mrs Miss Ms Dr Rev Other   Initials Surname

                                     House Number     

                                     House Name     

                                     Street Name     

                                     Town/City         

                                     Postcode            

                                     Email                  

                                     Daytime telephone number Not a Mobile Please

                                     Home telephone number     

                                     Special instructions