ORDER FORM

To order the two-disc DVD set of the inaugural meeting of the Hemifacial Spasm Association (HFSA) held July 18-19, 2003, in Pittsburgh, PA, please complete the form and follow the instructions below.

DVDs include Hemifacial Spasm presentations & discussions by Drs. Peter J. Jannetta, Amin Kassam, Anthony M. Kaufmann, Kenneth F. Casey, Jeffrey A. Brown and Robert J. Sclabassi.

(PLEASE PRINT or TYPE)

Name: _________________________________________________________________

Street Address: ___________________________________________ Apt./Ste.: _____

City: _________________________ State/Province: _________________

Country: ____________________ ZIP Code: _________________

Email Address: ___________________________          Telephone Number: (______)_______________

No. Sets Ordered: ________ ($30.00 (S/H Incl.) per set) Order total: $__________

Payment Method in USD:

(Check one.) PayPal®: _______ Check/Money Order: _______

Ordering Instructions for payment with PayPal®:

  1. Copy the above section of the form and paste it into a blank e-mail message form.
  2. Address the e-mail to jjo3-hfsa@hfs-assn.org
  3. Type "HFSA DVD" in the subject line
  4. Complete the information requested above
  5. Send the e-mail
  6. Click on the following link to get to our Contribute to the HFSA page and follow the PayPal® directions detailed there. (NO CREDIT CARD PAYMENTS ACCEPTED)
  7. You’re finished and as soon as the funds are received the DVDs will be mailed.

(NOTE: If you prefer not to submit via e-mail, print out the form, complete it and mail it to the address listed below; however, you may still submit the payment via PayPal®. Also, as long as you provide your full mailing address and telephone number in your PayPal® payment, you may disregard the form completely)

 

Ordering Instructions for payment with Check or Money Order (funds in USD):

  1. Print out this page.
  2. Complete the above section
  3. Mail completed form with your $30.00 check/money order (USD), made payable to HFSA to:

           Jack O'Donnell,  Treasurer
           HFSA
           3345 Kenmore Drive
           Sarasota, FL 34231-7131

           (Please allow 3-4 weeks for delivery via U.S. Mail.)