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Professional Order Form
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| "Health begins
and ends with the proper balance of the endocrine system" Broda O. Barnes, M.D., Ph.D. |
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To contact us: Broda O. Barnes, M.D. Research Foundation, Inc. P.O. Box
110098 Phone: 203-261-2101
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The fee for each information packet is $18.00. Residents outside the United States please add $3.00 per packet. All payments must be made in US currency. To order, please print the following form, complete and return it to: Barnes Foundation Credit card payments may be faxed 24 hours a day
to: ____ My first time contacting the Foundation ____ Please include information on 24-Hour Urine
Test First Name: _____________________ Middle Initial: ________ Last Name: _______________________ Degree: ___________ Affiliation: ___________________________________________ Address:____________________________________________ City: __________________ State: _______ Zip Code: ______________ Country: ________________________ Home Phone: ____________________ Work Phone: _________________ Fax Phone: _____________________ e-mail address: ________________ Please indicate total amount ____________How would you like to pay?Check or Money Order Enclosed
(payable to Barnes Foundation) _____________________ Account # __________________________________________ Expiration Date ________ Signature ___________________
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