Mail Order Form

Click on your printer icon to print this page and mail or fax it to us along with payment to ‘MediSpell’.
10824 Sheldon Road  Tampa, FL 33626  Fax: 813-902-6270

Date:

___________________________

Telephone:

(______) ________________________________ EXT ____________

Name:

________________________________________________________

Company:

________________________________________________________

Email:

________________________________________________________

Address:

________________________________________________________

City:

________________________________________________________

State:

______        Zip Code: ___________        Country:________________

Method of Payment:
P.O. Number:_________________ (Requires prior approval and copy of purchase order)

Check____    Visa____    MasterCard____    American Express____    Discover____

Credit Card Number:__________________________________ Exp. Date: ______/______   CVV ______

Name on Card:_____________________________________

Quantity

Description

Summer Sale Price
(expires August 15, 2015)

Total

   MediSpell – 1 User License $34.98 (Reg $69.95)
   MediSpell – 5 User License $90.00 (Reg $180.00)
   MediSpell – 10 User License $135.00 (Reg $270.00)
   MediSpell – 25 User License $200.00 (Reg $400.00)
   MediSpell – 50 User License $350.00 (Reg $700.00)
   MediSpell – 75 User License $450.00 (Reg $900.00)
   MediSpell – 100 User License $500.00 (Reg $1,000.00)
Subtotal:
Tax (7%):
(FL Residents Only)
Grand Total:
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