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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 $49.99/BOOK [S&H included] TOTAL= $______ CDROM QUANTITY[ ] x $49.99/CDROM [no S&H ] TOTAL = $______ FAX TO:
248.593.9037 | ||||||