You can also fill out a Feedback Form to send with your order
Order
Form
(see mailing/fax instructions below)
Please print your
practice name and address as you would like it to appear on your reports.
Practice Name:____________________________________________________________
Your Name:_______________________________________________________________
Address:_________________________________________________________________
_________________________________________________________________
City:________________________________ State:________
Zip:____________________
Office Phone: (_______)____________________ Fax:
(_______)___________________
E-mail ____________________________________________
Payment by:
Check Check number _________
Credit Card
Number ___________________________________________
Expires _____/_____
Name on card _________________________________________
Security Code ________
Street _______________________________________________________________________
Phone
(_______)_________________________________
Zip Code ________________
| ___ |
Purchase price |
$497.00 |
|
|
Additional Options |
|||
| ___ | Internet Entry one-time setup option - allows patients to fill in the Symptom Survey form on the internet. |
$297.00 |
|
| Please select a monthly internet subscription below: | |||
| ___ | 6 months pre-paid ($22/mo) |
$132.00 |
|
| ___ | 12 months pre-paid ($20/mo) |
$240.00 |
|
| ___ | Multi-User option – allows up to 5 simultaneous users on your office network. |
$250.00 |
|
| All prices include shipping and handling within the continental US. | |||
| New York State residents add sales tax |
___________ |
||
| If you are located within New York State, please enter the County you are located in below: | |||
| __________________________________________ | |||
| Total....... |
___________ |
||
Please print this form and mail or fax this completed form to:
Greene Software
Symptom Survey Maestro
P.O. Box 23
Victor, NY 14564
Phone: 585-924-4456 Fax: 585-924-8547 or
585-486-1947
sales@surveymaestro.com
http://www.surveymaestro.com