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SUBSCRIPTION MAIL ORDER FORM

Use this form to order and activate your annual subscription to the by mail. Simply follow the instructions below:

• Print out and complete the Subscription Mail Order Form.
• Please be sure to include your Email address, which will serve as the “Username” for your subscription. Once we receive and process your order, we will send you an Email that will include your “Password” so that you can access your subscription immediately.
• Mail this form to: Medifocus Legal, 6810 Park Heights Avenue, Suite C5, Baltimore, MD 21215

Subscriber Information

Email Address: ________________________________________________

Name of Subscriber: _____________________________________________

Law Firm/Company: _______________________________________________

Address Line 1: ________________________________________________

Address Line 2: ________________________________________________

City: __________________________________

State/Province: ______________________________

Zip/Postal Code: ____________

Phone Number: ________________________________

Preferred Payment Method

Check or Money Order – Please enclose a check or Money Order in the amount of $ payable to “Medifocus”.

Credit Card      __Visa __ MasterCard __ Discover __ American Express

Name on Card: ___________________________________

Card Number: ___________________________________

Expiration Date: ___/____

Authorized Signature: __________________________________

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Mail this form to:

Medifocus Legal, Suite C5, 6810 Park Heights Avenue, Baltimore, MD 21215

Questions? Please call us toll-free at 800-965-3002.

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