realord


	Diagnostic Data

You may e-mail the completed form, email the form and indicate to call you for charge card information or you may choose to print this form, then fax the order to (860) 561-4487.

Prices of the main programs and modules are located at the bottom of the form. All orders are placed through a secure server

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Last Name
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Credit Card Number
Expiration Date
Name on Card
Card type	MC VISA


	Please enter any additional order information in the space below.

I am interested in Code Search for:

Windows (single-user: program includes ICD9 - $295)
Windows (network: per additional user after purchase of single user- $50)
Windows (network: per additional user) How many?

Subtotal
Shipping/Handling
Tax (CT only 6%)
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Diagnostic Data