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  1.                                 Q.D. Systems
  2.                              1465 Fourth Street
  3.                           Berkeley, California  94710
  4.  
  5.  
  6.       FAX this form to 1-510-525-7496 or call us at 1-800-995-0475.
  7.  
  8.  
  9.                     YES! Sign me up for your Charter Offer.
  10.  
  11.         Check one:
  12.  
  13.               ___ Q.D. Clinical/Baseline Edition, $695
  14.                   (includes Quick Prescription module at no extra charge)
  15.  
  16.               ___ Q.D. Clinical/Extended Edition, $1,495
  17.                   (includes Quick Prescription, Procedures, Practice
  18.                    Research, Remote Access, Lab Management & Medical
  19.                    Database Access at no extra charge)
  20.  
  21.               Charter offer includes first year's maintenance.
  22.               Q.D. pays shipping and handling.
  23.  
  24.  
  25.  
  26.         Bill my: __VISA  __MasterCard  __American Express
  27.  
  28.               Name on card_______________________________
  29.  
  30.               Card number________________________________
  31.  
  32.               Issuing bank________________Expires________
  33.  
  34.               Signature__________________________________
  35.  
  36.  
  37.         Send me:   __ 3 1/2" disks    __ 5 1/4" disks
  38.  
  39.  
  40.               Name___________________________________________________
  41.  
  42.               Practice Name__________________________________________
  43.  
  44.               Medical Specialty______________________________________
  45.  
  46.               Street Address_________________________________________
  47.  
  48.               City/State/Zip_________________________________________
  49.  
  50.               Phone_____________________  Fax________________________
  51.  
  52.  
  53.                                    Money-back Guarantee
  54.  
  55.             If you are not completely satisfied, no matter what the reason,
  56.             simply return the software to us within ninety days. We will
  57.             immediately refund your money.
  58.  
  59.  
  60.