ORDER BY FAX OR BY MAIL TO BEGIN YOUR BIMONTHLY
SUBSCRIPTION
______________________________________________________________
Name Profession
______________________________________________________________
Institution/Clinic and Address
______________________________________________________________
City/State/Zip Daytime Telephone
_ ENCLOSED IS A CHECK FOR THE FULL AMOUNT __$35
_ PLEASE BILL MY CREDIT CARD __$35
MC/VISA___________________________________EXP.___________
AUTHORIZED SIGNATURE____________________________________
MAIL TO:
MINCEP Epilepsy Care
5775 Wayzata Boulevard • Minneapolis, MN 55416
FAX TO: 952-525-1560
www.mincep.com |