Selfheal and Amaranth cream order form

With a $48 donation to the Daisy Institute, you will expeditiously receive one cream of your choice, sent anywhere on the globe by air-mail, wherever public mail can reach.

Simply fill out the form here, in clear letters, and send it, along with your donation, to the Daisy Institute address below here:

Daisy Institute
6525 Wilderton Ave. Suite 710
Montreal, Qc. H3S 2L4  Canada

tel. (514) 733-2408

Family Name:__________________________Given Name:_______________


Street Address:_________________________________________________




Country:_______________________________Postal/ZIP Code:_________


Check the appropriate box with your donation, and indicate your choice and number of cream(s)

$48 $96 $86 other
Selfheal ___ Amaranth ___