Folio Referral and Analysis Application Order Page

To place an order for a single-user Folio Referral and Analysis Application, please fill out this form and click the "submit order" button at the bottom of this page. We will send you an invoice and license agreement to verify your order. You may also print this page and mail it with your check to the address at the bottom of this page.

For multiple-user applications, please call 1-800-223-2233 for custom pricing. To pay by credit card, please call us toll free or fax your order to the number below. All orders are subject to a signed license agreement.

Phone: 1-800-223-2233
Fax: 1-508-862-8210
E-Mail: customerservice@foliomed.com
Mail: Our address is at the bottom of this page.

PO Number:
Name:	Organization:
Department:	Phone Number:
Fax:	E-Mail:

Billing Address:		Shipping Address:
Street:		Street:
Town, State:		Town, State:
Zip Code:		Zip Code:
Attention To:		Attention To:
Ordered By:

PLEASE SELECT THE REFERRAL & ANALYSIS APPLICATIONS YOU WISH TO ORDER
Item	Physicians	Quantity	Facilities	Quantity
New England
Massachusetts	$750.00		$400.00
Connecticut/Rhode Island	$750.00		$400.00
Maine/New Hampshire/Vermont	$750.00		$400.00
New York
New York City & Long Island	$750.00		$400.00
New York Upstate	$750.00		$400.00
New Jersey & Ohio
New Jersey	$750.00		$400.00
Ohio	$750.00		$400.00
Sets
New England	$1750.00		$800.00
New York State	$1250.00		$500.00

Massachusetts residents will be charged 5% sales tax.

Processing and Shipping Charges:
$15 per order


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