(* Required Entries) *Name of Doctor: *Practice Name: *Street Address: *City: State: Alabama Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Select One *Country: Australia Belgium Brazil Canada Eire England France Germany Holland Italy Scotland South Africa Spain Switzerland New Zealand US Wales OTHER Other: *Zip/Postal Code: Phone: Fax: *Email: Referral Source: Another physician Journal Website Mailing Course Article Select One Interested in: Select One Basic Book Package Book Editing Book Writing Brochure Newsletter Website Upgrade Web Optimization Press Release OTHER Anne Akers, Publisher 350 Fifth Avenue, Suite 7619 New York, NY 10118 Tel: 212-983-5444 Fax: 212-973-0470 mdpublish@aol.com Newsletter Sign Up Full Name: Email Address:
Anne Akers, Publisher 350 Fifth Avenue, Suite 7619 New York, NY 10118 Tel: 212-983-5444 Fax: 212-973-0470 mdpublish@aol.com
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