Your personal ID card is just $18.00; Extra cards are $9.00 each. Ga. Residents please add 7% sales tax
Send check or money order with this form to: 

Thomas McGill
MY JOINT ID CARD
510 Wisteria Circle
Roswell, GA 30076-5014
Your order will typically be in return mail within one week of receipt.  www.joint-id.com
 

                                         MY JOINT ID CARD ORDER FORM

          
  Patientís Name
: ___________________________________Order Date:  _________ 

  Mailing Address:_________________________________________________________

 City _____________________________   State ______________________Zip____________

  Phone # ______________________                    Email__________________________

  Order is for one Primary Card_____ and  # of Extra _______Card(s)    Total # Cards_______

  Date of Surgery _________________   Implant Type:  HIP, KNEE or Other_____________

  Describe Other:_______________________________________________________________
_____________________________________________________________________________

  Right or Left side__________________    or Both (Bilateral)__________________________

  Doctorís Name: ___________________________Office Contact:_________________ _____

  Practice or Hospital Name:_____________________________________________________
_

  Office Address:  ______________________________________________________________
_____________________________________________________________________________

  Office Phone #__________________________________________
  Additional Data
Or, Special Requests:_____________________________________________
_____________________________________________________________________
_____________________________________________________________________

___


 

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