HealthHorizons.net - Order Form

Ordering

You may choose to complete this form and submit it by email if you are paying by credit card via RelayHealth. If you wish to pay by mail, please print this page and send the completed form with your check or money order to the address below.

Contact Information
Name
Address		Street

		City
		State or Province	^or
		Zip/Postal Code
Phone (incl. area code)
Fax
Email

Products & Services*
		Living Will ($100)
		Travel Information ($50)
		Medical Records Review (cost arranged by discussion according to length of records to be reviewed)
		Disease Information (~~$50~~) * Special offer--now only $25! *
		*All of the above include up to 15 minutes telephone discussion with Dr. Long
	Your medical questions:
		15 minutes (~~$50~~) * Special offer--now only $20! *
		30 minutes (~~$75~~) * Special offer--now only $35! *

Comments

Payment Options
		By credit card Sign up (for free) at RelayHealth
		By mail Print out this form and mail it with your check or money order to Thomas E. Long, M.D. P.O. Box 578 Gig Harbor, WA 98335.



Questions?		Contact us by email at info@healthhorizons.net or by telephone at (253) 857-9001.

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Contact Information

Products & Services*

Payment Options