Brain Foundation
Cefaly Order Form
Name:
______________________________
Address: ______________________________
______________________________
Email:
______________________________
Phone:
______________________________
□ Cefaly Machine $320.00 (including GST)
□ Electrodes: $24.00 (Per packet of 3)
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Paid by:
Cheque (payable to the Brain Foundation)
Charge to my MasterCard / VISA / Amex
Cash
Card No:
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Expiry Date:
___ / ___
Name on Card:________________________________________________________
Signature:
________________________________________________________
Please return this completed form by either:
Email: info@brainfoundation.org.au
Mail to: Brain Foundation, Reply Paid 579, Crows Nest NSW 1585
Fax: (02) 9437 5978
A registered charity dedicated to the advancement of Brain Research