realord


	Diagnostic Data

Please fill out the form, print it out and then FAX the form, as a precaution, to 860-561-4487. You may also indicate on the form to call you for charge card information

Unfortunately, we had to increase the cost of the program due to the substantial fees being imposed by the credit card companies.

First Name
Last Name
Company/Suite
Address
City
State
Zip
Telephone number
Fax Number
Email address
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- $40)
Windows (network: per additional user) How many?

Subtotal
Shipping/Handling
Tax (CT only 6%)
Total

Diagnostic Data