ORDER FORM

Thank you so much for your Order ! Please allow two weeks for delivery.

fax: 941-379-8143  •  supertools@comcast.net  •  Office: 941-954-1909

FULL PACKAGE INCLUDES ALL

LICENSE FEES ARE THOSE IN EFFECT AT TIME OF ORDER

$

SuperBill ^™

COMPREHENSIVE INTAKE

PHYSICIAN'S RX WITH UNIVERSAL TREATMENT PLAN

REFERRAL THANK YOU                   PROFESSIONAL & CLIENT VERSIONS

GIFT CERTIFICATE                    Circle style - Standard   Postcard

WELCOME POSTCARD

REMINDER POSTCARD

INVOICE FOR PATIENT RECORDS

CARRIER NOTICE - PAYMENT DELAY

CARRIER NOTICE - TREATMENT COMMENCEMENT

PATIENT ACCOUNT SUMMARY

LAWS GOVERNING PAYMENT TO FL LMTS

complimentary

for full pkgs

ALL ORDERS ADD      (Under $50 = $4.50)     ($50 or More = $7.50)

S / H

$

CHECK • MONEY ORDER • MC • VISA • AMEX • DISCOVER            CIRCLE PMT TYPE

Cks & MO PAYABLE TO: SHERRY SMITH, LMT

TOTAL

$

CREDIT CARD PAYMENT

Cardholder Signature

Billing Address

Card Number                                                                                       Exp Mo & Yr                          Ph

$uperTools ^™ are Personalized EXACTLY AS INDICATED BELOW

Therapist Name & Designation (s)

Ex: LMT, NMT, CT, RPP, MT, PT

Therapist Lic

2 letters, 7 digits (FL)

Establishment Lic

2 letters, 7 digits (FL)

Mailing Address

City & State

Zip + 4

Office Phone

Fax

Pager or Cell    Circle one

E-mail

Web Site

Blue Cross-Blue Shield

Provider #

Fed Tax ID #

Choose one

Soc Sec #

____ ____ ____ - ____ ____ - ____ ____ ____ ____

Include Colon Hydrotherapy

on SuperBill ^™

For referral incentive, complete sentence

"Please bring this Thank You to your next treatment and receive …"

Option 1, Standard Incentive:

"a $5 reduction on your treatment or the purchase of a Gift Certificate"

__ YES     __ NO

Option 2, Create Your Incentive:       max 70 characters & spaces

__ YES     __ NO