[Information Retrieval: Medical Information Updates]

Medical Information Updates Form

To receive your medical information updates, please fill in this form.

Upon what topic do you wish to receive monthly updates? Be as specific as you can. For example, colon cancer treatments.

Tell us how to get in touch with you:

Name:
Address:
AM Phone:
PM Phone:
FAX :
E-mail:

Choose how often you wish to receive your updates:

Weekly Biweekly Monthly Quarterly

How many months do you wish to sign up for?

Choose the method you would like to use to receive updates:

E-mail First Class Mail Express Mail

We will contact you with a price quote based upon your desired frequency and scope.

Security Caution

Information you enter on this form is not secure. It is possible for someone other than the intended recipient to view this information while it is being transmitted. If you have any reservations about the vulnerability of your information, it would be wiser to call MIU and submit your information over the phone by calling 1-541-267-2205.