2nd Opinion Order Form

Order Form:

2nd Opinion Specialists Directory

How to use this Form:

Use one Form per practice/organization. To reduce "Banner", click on its "UPPER" right arrow.

Type in the Form, on screen response, (fill out all applicable blanks).

Press "TAB" to move between blank spaces. When finished, please print the Form.

Preferred payment: Check drawn on an American bank.

Acceptable payment: International Money Order or a check drawn on a local bank by using your country's currency.
Our bank will send the check back to country of origin for collection. The process usually takes about 3-4 weeks.

	Listing/web site link only (no description): Special Fee: $69/year (Regular Fee: $195/year)
	Listing/web site link plus description: Special Fee: $99/year (Regular Fee: $235/year)

Special Fee Deadline: Contact DMS

Arabic Page development: JPEG

TOTAL Fee: Add amounts from selected boxes above and enter here $
Date. Check Number.

ORDER INFORMATION: (Please complete only applicable information)

Name	.Title
Special Interest
Department
Institution
Address
City	.State/Postal Code ..Country
Country Code	.City/Area Code. Telephone number ..FAX number
E - Mail Address
Web Site Address

Please Print Completed Form And Mail It With Your Payment To:
Doctors' Marketing Service
P.O. Box 748, Lake Forest, California 92630-0748, USA
(949) 472-3767
Back To Home Page

		Use one Form per practice/organization. To reduce "Banner", click on its "UPPER" right arrow.
		Type in the Form, on screen response, (fill out all applicable blanks).
		Press "TAB" to move between blank spaces. When finished, please print the Form.
		Preferred payment: Check drawn on an American bank.
		Acceptable payment: International Money Order or a check drawn on a local bank by using your country's currency. Our bank will send the check back to country of origin for collection. The process usually takes about 3-4 weeks.