ORDER FORM

Please print out this order form and send it along with a money order payable 
to Dr. C. G. Brodie-Brockwell at the address below. (Please Print)

First Name: _____________________________________________________ 

Last Name:  _____________________________________________________

Street Address:___________________________________________________

City: __________________________Apt #:  ___________________________ 

Postal/Zip Code  :_________________________________________________

Prov/State: ____________________ Country:  __________________________

Contact Phone Number : __________________________________________

Please select the book(s) you wish to purchase and the number of copies:

  "The Myofascial Syndrome Its Causes and Treatment"  Quantity: 1 2 3 4 5 (circle choice)
                                    $45.00 Cdn. Funds   OR        $30.00 U.S. Funds   
   NEW!" Migraine The Causes and Treatment"                Quantity: 1 2 3 4 5 (circle choice)
                         $25.00 Cdn. Funds   OR        $15.00 US. Funds