____________________________________________________
Name

____________________________________________________
Address

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City, State, Zip

PAYMENT METHOD (Circle One):

Visa, MasterCard, Check (Circle One)

BILL TO/CREDIT CARD INFO:

____________________________________________________
Name on Card

____________________________________________________
Card Number

____________________________________________________
Expiration Date

____________________________________________________
Signature

Price: $14.95 plus $3.00 Shipping and Handling, Total = $17.95.

Florida Residents Only:
$14.95 + .90 (6% FL. sales tax) + $3.00 S & H, Total = $18.85

If paying by check, please make payable to: Dr. Lawrence Lampert, O.D.