To order the lecture video entitled: "Your Bladder & You...Who's Boss?" please print this page, fill in the information, and fax or mail it to:

The Urology Wellness Center,
Attn: Lecture Video Order
13925 Bergenfield Dr.
Gaithersburg, Md. 20878

Phone: 310-762-5177
Fax: 301-762-4243

The cost is $23.95 plus $4.95 S&H. We accept Visa/Mastercard, Checks, or Money Orders. For orders that are paid by check or money order, video will be mailed once payment is received.

NAME:____________________________________________________

MAILING ADDRESS:_______________________________________

CITY, STATE, ZIP:__________________________________________

PHONE:__________________

NUMBER OF VIDEOS YOU WISH TO ORDER:_______

PAYMENT METHOD:

CHECK: _____ MONEY ORDER: _____


Cost is $23.95 plus $4.95 S&H. Total is $28.90 and will be charged to your credit card if that method of payment is chosen.