MDforms.com: Order Form

Patient Education Kit Order Form

Fill out the form below, indicating the Basic Kit you'd like to order, as well as any Extras or Upgrades you'd like to purchase. After you've made your selections, indicate whether you would prefer to pay by check or credit card, and hit Send to MDforms. Your order will be forwarded to our fulfillment center, and a member of our customer service staff will call you to confirm your order and process your payment. If you have any problems while submitting your order, please contact us at 301-527-8897.

Required fields are in bold.
Practice Name:
Primary / Billing Address:
City:
State:
Zip Code:	-
Phone:
Fax:
Web site Address (URL):

Contact - First Name:
Contact - Last Name:
Contact - Salutation:	·(Mr., Ms., Dr., etc.)
Contact - Title:
Contact - E-mail:
Contact - Phone:	Ext.:

Practice Information
Type of Practice:
No. of Practitioners:
No. of Offices:
Medical Soc. Memberships: (Separate by commas)

Build Your Patient	Education Kit
Basic Kit Requirements:
Imprinting:
Additional Copy: (Use to list additional offices, doctors individually, etc.Type line-for-line, as you want it to appear.)
Custom Imprint Options:	We want to add our logo.
(Check all that apply.)	Add / match logo or corporate color.
	Use photos of our staff.
	Photos printed in color.
	Modify "customer service" copy.

ACKNOWLEDGEMENT &
CONSENT Forms	Standard Imprint–Name/Address: $24.95 setup.
(click here for Details)	Custom Setup–logo/letterhead, text changes: $49.95.
	(If you select "Custom Setup" a we will contact you to discuss your needs.)

Upgrades & Extras
Deluxe	Upgrade to Deluxe Double Rack - $17.95.
Literature Displays	Add'l. Deluxe Double Racks - $21.95 each.
	Upgrade to Smoked Plexiglas - $10.95 ea.
	Add'l. Smoked Plexiglas - $12.95 each.

Posters	Extra Waiting Room Posters - $5.95/set.
	Exam Room Mini-Posters - $3.95/set.
	Mounted Waiting Room Posters - $169/set.
	Mounted Mini-Posters - $89/set.


HIPAA Hotline

Payment

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