|
MUE Manager Order Form Order Form in PDF |
||
|
User's Name (Will print on reports; facility name not allowed: ______________________________________________________________ Facility/Hospital/Pharmacy Name: ______________________________________________________________ Address:_______________________________________________________ Phone:____________________________ Fax:________________________ Email address where software is to be sent Please print clearly: ______________________________________________________________ Select the Database Set(s) you want to order ($269.00 each). Long-Term Care Hospital Psychiatry Infectious Disease Payment Methods: Check Master Card Visa Master Card / Visa Card Number:__________________________________ Expiration Date:______________________ Signature:__________________________________ Date:______________ Fax Completed Forms (for charge card sales) to (757)625-4538. Mail Completed Forms (for check sales) payable to: Insight Therapeutics,LLC 129 W. Virginia Beach Blvd., Suite 105 Norfolk, VA 23510 © 2002 Insight Therapeutics, LLC |