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ORDER ENTRY FORM: Textbook of Bio-Identical Hormones |
Edward Lichten, M.D.,PC Print Order Entry Form |
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Ship To:Name: ___________________________________ Address: ____________________________________ City/State/Zip: ____________________________________ Telephone No.:_______ _________ ___________ _______ Shipping: United States Postal Service: 3 day ground add $6 S&H/ book Bill To:Name: ____________________________________ Address: _________________________________________ City/State/Zip: _____________________________________ Telephone No.:____ _______ __________ _____________ Credit Card: Card Company: [MasterCard_] [VISA_] [Discover_] [Am. Express_] Credit Card No: _____ _______ ______ _____ Expiration Date: ____ ______ V-code: _______ Sign Name: _______________________________________ BOOK QUANTITY [ ] x $55/BOOK [S&H included] TOTAL= $______ CDROM QUANTITY[ ] x $49/CDROM [no S&H ] TOTAL = $______ FAX TO: 248.593.9037 EMAIL TO: <book order> drlichten@yahoo.com MAIL FORM TO: Edward Lichten MD PC, Birmingham, MI 48012-0843 | ||||||