Radiology Clinic Stationary Order Form

Radiology Clinic:*

Contact Person:*

Ship to Address:*

Street Address Address Line 2 City Province Postal Code

Any change in your clinics address or information?*

Specify change to clinic address or information:*

Phone:*

Email (optional):

Fax (optional):

Clinic Letterhead*

Canada Diagnostic Centres - Calgary*

Canada Diagnostic Centres - Edmonton*

Medical Imaging Consultants*

Specify number of Letterhead packages for each clinic selected:

(Packages of 500)

Specify number of Envelope packages for each clinic selected:

(Packages of 500)

Please allow 30 business days for order and delivery.

For inquiries call toll free: 1-866-727-3926

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