Email Questions to
To order from, call 626-643-0331

or use this order form
City                                               State                                                  Zip
Country                                                     Year of mastectomy
Phone (       )                                              Email address
Qty Style# Size Color Description Each Total
Total for merchandise $      .       
Sales tax (see paragraph below)  
Postage and handling $10.00  
TOTAL $      .       
Thank you for your purchase.
Sales Tax: Pursuant to Regulation 1591 of the California Board of Equalization, mammary prostheses are "deemed to be dispensed by prescription" and are therefore not a taxable item if you are purchasing one to be worn after a lumpectomy or mastectomy. Bras that are pocketed to hold prosthetic devices (breast forms) are also not taxable if you are purchasing for use after a lumpectomy or mastectomy. If you are purchasing a prosthesis or pocketed bra and it is not for medical use, and you live in California, your rate of tax is approximately 7%. If your purchase is not for medical use and you live in Los Angeles County, your rate of tax is approximately 8%. If you live anywhere else, your purchase is classified as interstate or foreign commerce and is not taxable.

Print this order form, fill out information and mail to:

Jayne Sjodin
Graphic Ad Ventures

605 East I Street
Ontario, CA 91764

Please make checks or money orders out to Graphic Ad Ventures

Nearly Me Forms | Trulife Forms | American Breast Forms
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605 East I Street, Ontario, California 91764 • 626-643-0331

©1999 Boob Boutique, All rights reserved
Boob Boutique is a subsidiary of Graphic Ad Ventures

©1997 Graphic Ad Ventures, All rights reserved

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