The Health Care Crisis
5401 Palm Dr. | Fort Pierce, FL 34982
Book Order Form
(Please Print)   
Name:
Address:
City: State: Zip:
Phone (day) Phone (night)
  1.  Print CLEARLY and ACCURATELY to ensure prompt delivery.
  2.  Please DOUBLE-CHECK your order and the amounts.
 Item Description  Price Quantity Total Amount
The Health Care Crisis $24.95    
         
         
         
        
Subtotal    
Shipping  
$4.95
TOTAL    
Enclosed is the FULL amount of my order.
Circle Payment method:
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Signature:
 
If paying by check make check payable to:
Dr. Harold Lee
Mail to:
The Health Care Crisis
Dr. Harold Lee
5401 Palm Dr.
Fort Pierce, FL 34982

Phone: 772-464-7736
E-mail me at:
drharoldlee@hotmail.com