Back Talk Systems Inc. - Therapy Card Order Form

Therapy Card Order Form

Please use this form to order Therapy Cards. After submitting this form one of our customer service representatives will call you to collect payment for your order.

All Therapy Cards cards are customized with your practice information. Back Talk Systems uses this form to collect all information needed to customize your Therapy Card cards.

If you do not wish to include information from one of the requested fields, please leave it blank.

Section 1: Proofing Information

	Contact Name:
	Fax Number:
	Email:

Section 2: Customization Information

	Clinic Name:
	Doctor Name:
	Address 1:
	Address 2:
	City:
	State:
	Zip Code:
	Phone Number:
	Website:

Section 3: Fonts

Section 4: Therapy Cards and Quantity

Cryotherpy Therapy Card:			Therapy Card prices are based on the total number of Therapy Cards you purchase. 100 @ .39 each = $39.00 200 @ .30 each = $60.00 300 @ .27 each = $81.00 400 @ .24 each = $96.00 500+ @ .23 each = $115.00
Electro-Muscle Therapy Card:
Intersegmantal Therapy Card:
Excercise Therapy Card:
Superficial Heat Therapy Card:
Massage Therapy Card:
Ultrasound Therapy Card:
Interferential Therapy Card:

Section 6: Notes

Please include any notes that would help us finish your order to your satisfaction: