DMS Lab Result - Order Form

^{Portable Web Site -
Lab Results}
ORDER FORM

How to Use This Form:

Type in the form, on screen response, (fill out the blanks) and enter all applicable information
Press TAB to move from one field to another
If you make a mistake, erase/delete and retype correct information
Click on underlined titles to view list information. Please click "Back" to return to this list.
Print Form and mail it with your payment to: Doctors Marketing Service address (shown below)

Please enclose the following items:

Completed Order Form

Payment (check only. No credit cards).

Orders from outside the USA, please send a Money Order in your country's currency.

Total Order:
To avoid any delays in processing your order, kindly double check all selected categories and enter appropriate rates.

Total Amount Paid: $
Check #

Mailing Date:

COMMENTS:

ORDER INFORMATION:

Name
Title
Department
Institution
Address
City	State/Zip Code:
Country
Area Code	Telephone number: FAX number:
E.Mail Address
URL (web site address)

>>> Please Print Completed Form And Mail It With Your Payment To:

Doctors' Marketing Service
P.O. Box 748
Lake Forest, California 92609-0748, USA

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