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