SECURITY
CODE
ZIP CODE
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| DANGER ZONE: UNLOCK THE SECRETS OF NURSING HOME MEDICAL RECORDS | |||||||||
| AND PROTECT YOUR LOVED ONE | |||||||||
| ORDER FORM | |||||||||
| NAME: | |||||||||
| ADDRESS: | |||||||||
| CITY: | STATE: | ZIP CODE | |||||||
| PRICES INCLUDE SHIPPING BY USPS PRIORITY MAIL | |||||||||
| SINGLE COPY PRICE: $16.95 -- MARYLAND RESIDENTS PAY 6% SALES TAX: $17.97 | |||||||||
| DISCOUNTED PRICES FOR MORE THAN 10 COPIES AND FOR FAMILY COUNCILS. | |||||||||
| PLEASE CONTACT OUR OFFICE FOR PRICES: 410-421-9100. | |||||||||
| # OF COPIES X $16.95 = ORDER TOTAL: | |||||||||
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| TO ORDER BY PHONE: | |||||||||
| CALL 410-421-9100 MONDAY-FRIDAY 9:00AM - 4:00 PM EST | |||||||||
| PLEASE HAVE CREDIT CARD INFORMATION AVAILABLE | |||||||||
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| TO ORDER BY FAX OR MAIL: | |||||||||
| VISA | |||||||||
| MASTERCARD | |||||||||
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EXPIRATION: | ||||||||
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SECURITY |
CODE |
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| CREDIT CARD BILLING ADDRESS IF DIFFERENT THAN ABOVE | |||||||||
| ADDRESS | |||||||||
| CITY | STATE |
ZIP CODE |
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| SIGNATURE: | |||||||||
| FAX FORM TO: 410-544-4463 AVAILABLE 24 HOURS | |||||||||
| OR | |||||||||
| MAIL TO: | MEMBEROFTHEFAMILY.NET | ||||||||
| 670 RITCHIE HIGHWAY | |||||||||
| SEVERNA PARK MD 21146 | |||||||||