Vein Disorders Center -- Order Form

Ordering and Reservation Center

Registration Application-1996


Name..........
Address.......
City..........
State.........
Zip...........
E-mail Addr...
Phone No......

CHECK WHICH WORKSHOP YOU DESIRE? (select one)

 April 
 September
 November

Make a check payable for $1250.00 to:
Vein Disorders Center.  Print out this form
and send it to:

Vein Disorders Center
16311 Ventura Blvd Suite 505
Encino, CA 91436

or call 1-800-SEW-VEIN with you credit card order.

Your Name:
Order our tapes, videos and book here!

Shipping and
billing address: Street:

City:

State: Zip:

Item Qty Price Qty times Price

Invaginated Axial Stripping Video. $250.00

Examination of the Venous Systems Video $150.00
High ligation & compressibe sclerotherapy Video $150.00
Microsclerosis for telangiectasia $150.00

Practitioner's Guide $95.00

Sub Total
California Residents add 8.25% S. Tax
United States Residents add $5.95 U.S. for shipping and handling
Foreign orders please include $19.95 U.S. for shipping and handling

If you purchase the set of all 4 tapes and attend the workshop as well, receive a 20% discount from the workshop fee, a savings of $250.00.

Order Total

Item	Qty	Price

Shipping and billing address:	Street:
Shipping and billing address:	City:
State:		Zip:
Invaginated Axial Stripping Video.		$250.00
Examination of the Venous Systems Video		$150.00
High ligation & compressibe sclerotherapy Video		$150.00
Microsclerosis for telangiectasia		$150.00
Practitioner's Guide		$95.00

Sub Total
California Residents add 8.25% S. Tax
United States Residents add $5.95 U.S. for shipping and handling Foreign orders please include $19.95 U.S. for shipping and handling
If you purchase the set of all 4 tapes and attend the workshop as well, receive a 20% discount from the workshop fee, a savings of $250.00.
Order Total