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Document Ordering Page


To order:
(1) You can cut and paste this form into an attachment to an email to alewis@dismgmt.com
(2) You can print this form, please use the PRINT function on your Browser. Print this form and RETURN VIA FAX (if credit card) OR REGULAR MAIL or
(3) You can simply CALL IN a credit card or invoice request to 781 237 7208

ALL CREDIT CARD ORDERS WILL BE EMAILED THE SAME DAY

Name:     ______________________
Title:    ______________________
Company:  ______________________
Address:  ______________________
City:     ______________________
State:    ______________________
Zip:      ______________________
Phone:    ______________________
Fax:      ______________________
Email:    ______________________


Documents ordered

Filename                 Price    

                                  

                                  

                                  

                                  

                                  


IF PAYING BY CREDIT CARD:

Credit Card:
___Visa
___American Express
___Mastercard
Number:       ________________________
Expires:      ___/ ___
Name on Card: ________________________
5-Digit Billing Zip Code:  _________
   

Disease Management Purchasing Consortium International, Inc.
57 River Road, #102
Wellesley, MA 02481
Phone: is 781 237 7208
Fax: 781 239 0914
Email: alewis@dismgmt.com