Yes! I would like to claim my copy of “Basic Principles in Orthotic Therapy and its Clinical Application”
I understand that the information in this course will provide a proven method on how I can help my patients achieve a better quality of life through orthotic therapy, while at the same time expand my practice profits many times over year after year.

I also understand that this course has a “12 month full refund guarantee” if for any reason I request a refund “Cybermedical Pty Ltd” trading as “Cyberorthotics” will refund the cost of this course to me in full.
Name: _________________________________________________
Email: _________________________________________________
Company (optional): ______________________________________
Address: _______________________________________________
(please be sure to enter a physical mailing address, if you enter a P.O. box, your course will
be sent by regular post and can take up to 2 weeks to arrive)
City: __________________________________________________
State: _________________________________________________
Country: _______________________________________________
(please check your shipping costs below)
Post Code: ____________
Phone: (___) ________ - _________


Please check one of the following:
(  ) I would like to order “Basic Principles in Orthotic Therapy and its Clinical Application” with a one-time payment of $395 (Australian dollars) on CD plus postage and handling (see below)
Country Australian dollars
Australia
32.08
(  ) I am enclosing a cheque or money order.( Please write the cheque out in the name of “Cyberorthotics” and note that we do not accept a cheque by fax, so if you are paying by cheque you must mail it in.
(  ) I want to charge my Credit Card.

***Please note if you are ordering “Basic Principles in Orthotic Therapy and its Clinical Application” on CD there will be postage and handling charges (see above)***

Credit Card (check one):
VISA
MasterCard
American Express
Expiry Date: _________
Signature: _________________________

I authorize “Cyberorthotics” to charge my credit card $395 plus postage and handling (if applicable) to my credit card for the purchase (and shipment) of “Basic Principles in Orthotic Therapy and its Clinical Application”