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Order Form

Genetic Sonography

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___YES I want to order the program Genetic Sonography at the price of $450.00

Name_________________________________________________________

Street Address__________________________________________________

Suite or Apartment Number__________________

City______________________________

State/Province___________________________

Country________________________________

Postal Code_____________________________

Telephone Number____________________________

Fax Number_________________________________

E-Mail _______________________________@____________________

Please debit my Credit Card (American Express, Visa, Mastercard)

Card Nu:___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ______ ___ ___ ___

Exp Date: ___ ___/___ ___

Number of 4 CD-ROM Complete Programs:_____ at $450.00/4 CD-ROM Program Total_________________

Signature__________________________

Order by FAX:

Inside the United States: 626-583-8894

Outside the United States: 01-626-583-8894

Order by Mail:

Greggory R. DeVore, MD

Suite 206

301 South Fair Oaks Ave

Pasadena, CA 91105

USA