Page title

1. Select Your Book Cover Option:

2. Please complete this information EXACTLY AS IT SHOULD APPEAR IN CAMPAIGN PIECES

(The information entered here will be used to customize books and emails your leads will receive!):

Original Book Title:

Practice Name:

Signature Line (how would you like your emails signed?):

Office Street Address:

City/State/Zip:

2nd Address:

City/State/Zip:

Office Phone:

Email Address:

Fax:

Web Address:

3. Your Information

First Name

Last Name

4. Choose your option:

I have previously done a Top Practices HEEL PAIN book – $895

This is my first Top Practices HEEL PAIN book – $1495

5. Payment Method

Billing Address

Billing Address 2

Billing City

Billing Country

Billing Zipcode

Card Number

CVC

Confirm CVC

Top Practices retains ownership of all artwork (except original artwork submitted by client), written material, and intellectual property used in this project. Although finished books have copyright in your name, this is a courtesy copyright title for purposes of effective Top Practices style practice marketing, and all ownership is retained by Top Practices. You do not have the right to print or reprint the book(s) without the express consent of Top Practices. All books must be ordered from Top Practices directly. Top Practices accepts no responsibility for compliance to any local, state, or federal regulations regarding marketing by this profession, including HIPAA regulation, this responsibility lies solely with the client.

I have read and accept all terms of this agreement.

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