Martin Avenue Pharmacy, Inc. -- Register

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* First Name:
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City:
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At this time, I am requesting the following information please be sent to me: (please check all that apply)

Other Compounding topics:
	Animal Compounding Brochure
	Compounding Brochure
	Dental Compounding Brochure
	Flavoring Brochure
	Pain Management Brochure
	Transdermal Medication Brochure

Saliva testing Information:
	The Post Menopause Hormone Panel Brochure
	The Thyroid Panel Brochure
	The Male Hormone Panel Brochure
	The Adrenal Stress Index Brochure

Hormone Replacement Therapy:
	Female Natural HRT Brochure
	Andropause - Restoring Vitality Brochure

Tell us a little bit about yourself, are you a...

	Doctor			Customer
	Veterinarian			Other (specify below)
	Dentist
	Pet Owner

How did you hear of us? (please check all that apply)

Television:

	Wide Open West (WOW)
	AT&T Cable
	Other

Web Site:

	SuburbanChicagoNews.com
	DailyHerald.com
	Naperville.net
	Other

Radio:

	The River 95.9 FM
	WBIG 1280 AM
	WRXQ 100.7 FM
	WJOL 1340 AM
	Other

Newspaper:

	Daily Herald
	Chicago Tribune
	Sun Publications:

	Other

Other:

	Yellow Pages
	Company Literature
	Word of Mouth
	Search Engine
	Not Listed: (specify below)

Martin Avenue Pharmacy, Inc.
Naperville, IL • Phone: 630-355-6400 or Fax: 630-355-6522
All Compounded Medications require a written prescription from a Physician.
Copyright © 1997, 1998, 1999, 2000, 2001, 2002 by Martin Avenue Pharmacy, Inc.
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