
                        *** ORDER FORM        PAGE 1 ***

     Complete this form and mail with required fee to register LEHIPEDS.
     Your registered software will be sent on the next business day after
     we receive your order.

     REGISTRATION INFORMATION:

     Name of Registered User:_____________________________________________

     Name of Practice:____________________________________________________

     Address:_____________________________________________________________

             _____________________________________________________________

             _____________________________________________________________

     Phone:_______________ FAX:_______________ Email:_____________________

     Other Info:__________________________________________________________


     PRICING INFORMATION (Prices are subject to change without notice):

     The regular license price for LEHIPEDS is $325.00 plus postage.  This
     price is the same for use as a single user program or as a network
     program. The program runs equally well in either mode. A network is
     defined as any number of connected computers associated with one
     medical practice in a single office. For this, one license is needed.

     If you use the program in different offices, or use the program in
     different medical practices within the same office, you must purchase
     a site license. Refer to Manual for information about site licenses.

     As a special introductory offer, through December 31, 1996, we are
     offering LEHIPEDS registration at the unbelievable value of $125.00.
     This special offer does NOT apply to the site license price.

     LEHIPEDS Registration...................... $325.00   ______________
     LEHIPEDS Registration
       Special Price thru 12-31-96.............. $125.00   ______________
     Non-Registered Disks for evaluation
       Applied to price when registered......... $ 15.00   ______________

     Site License: Must purchase single registration for first site.
     Special price above does NOT apply for registration of first site.
     Each additional site (multiple offices or practices) is $150.00.

     Number of additional sites......... ____  @ $150.00   ______________

     Postage & handling......................... $ 10.00         10.00

                              TOTAL ....................   ______________

        

                        *** ORDER FORM        PAGE 2 ***




     ** Payment by check or money order...

        Mail payment + this order form to:

                     Marilyn S. Holt
                     1140 Lee Blvd. Suite 108
                     Lehigh Acres, FL 33936


                            . . . . . .


     ** Payment by credit card...

        Complete the following information:

        Master Card (  )    VISA (  )

        Card Number: ____________________________________________________

        Expiration Date: ________________________________________________

        Name of Card Holder _____________________________________________

        Signature of Card Holder ________________________________________


        Three ways to pay by credit card:

           - Mail BOTH PAGES of order form to address indicated above.

           - FAX BOTH PAGES of order form to: (941) 368-1331

           - Telephone order/credit card information to: (941) 368-3810


                            . . . . . .


     Disk Size (will send 3 1/2" if not specified):

             3 1/2" (  )    5 1/4" (  )





             THANK YOU FOR SUPPORTING THE SHAREWARE CONCEPT!


        
