PFSS Fax Order Form

PHYSICIAN'S FEE SCHEDULE SOFTWARE
Order Form

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Mail Orders:

FCMC Professional Software | 1340 Leyden Street | Denver, CO 80220

Fax Orders:

(303) 320-1828

Inquiries:

If you have questions, please call (303) 320-8686

Thank you for your interest in PFSS!

Today's Date:

___________________________

Company Name:

______________________________________________________

Contact:

________________________
Name

______________________
Title

________________________
Phone

___________________
Fax

Practice Type:
(Circle One)

Hospital IPA HMO Group Practice (Specialty): _____________

Other: (Specify)_________________________________________

Address:

____________________________________________
Street Address

____________________________
City

_______________
State

____________
Zip

*Quantity*	*Item*	*Amount*
________	PFSS Version 11.0 (CD-ROM only) $325	$____________
________	Additional Copies of PFSS v11.0 @ $225	$____________
________	Primary Care 2010 (CD-ROM only) $175	$____________
________	Additional Copies of Primary Care @ $150	$____________
Tax:	Colorado Residents add 7.3% Sales Tax	$____________
Shipping:	US Postal Service Shipping @ $8.00 each	$____________
	2nd Day Air Delivery @ $20.00	$____________
	Overnight Shipping @ $35.00	$____________
	TOTAL:	$____________

Credit Card Payment:

Circle One:

Expiration Date:_______________

_______________________________
Account Number

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Cardholder Signature

Check Payment

Pay to: FCMC Professional Software Check #________