Welcome to the Physician Referral Handbook

ORDER FORM

Facility / Office
Contact person
Address
Suite No
City
State
Zip
Phone Number
Fax Number
Email Address
Handbook Quantity		@$20.00 each (up to 24)
		@$18.00 each (25 or more)
Tax Exempt?
		Shipping charge: $2.50 for first book, $0.25 for each additional book. We do not accept credit cards. You will receive an invoice with your book(s). Tax: per your county (include book total and shipping to determine total tax - per state guidelines)