Don Self and Associates, Inc.
FAX 1-866-366-7329
|
Your name? |
||
|
Practice/Bus. name?
|
||
|
Specialty?
|
||
|
Street/Shipping Address? (No PO Box)
|
||
|
Is this a Business or Residence?
|
||
|
City/State/Zip?
|
||
|
A/C & phone #?
|
||
|
A/C & fax #?
|
||
|
Purchase order/number? |
||
|
Quantity Ordered?
|
||
|
Your email address:
|
||
|
Credit Card MC/Visa :
|
||
|
Credit Card Number:
|
||
|
Expir. Date
|
||
|
Card Holder Name :
|
||
|
CC Billing Address :
|
||
|
CC Billing Zip Code :
|
||
|
|
||
|
Special mailing requests?
|
||
|
|
||
|
Don publishes a monthly
8 page newsletter on collections, coding and reimbursements. Would you
like us to email you a free issue of our monthly newsletter to see if
you like it, with no obligation on your part?
|
||
|
Circle One:
|
Yes, please email one to me No thank you |
|