Order Informational Folder

1) Please tell us about yourself

First Name
Last Name
Title
Address
City
State
Zipcode
Company
Phone
Fax
EMail
	Please put me on your email list for product updates.

2) Please describe your company

Family Physician OB/GYN Hospital Community Health Center Public Health Clinic HMO Family Practice Residency OB/GYN Residency Insurance Company Other

3) Please tell us about your use of the World Wide Web

• What browser do you usually use when working on the Web?
  

• Is your primary Internet/Web connection:
  At work At home Other (please specify):

• How much time per week do you spend on the Web?
  0 - 3 Hours 4 - 6 Hours 7 - 10 Hours More than 10 Hours

• The above time is spent (please check all that apply):
  Looking for information that pertains to your career
  Looking for information on commercial products/services
  Interacting with other people on the Internet (newsgroups, chat, etc)
  Researching academic topics
  Browsing for entertainment purposes

• Have you ever purchased anything over the Internet/Web?
  Yes No

• Do you worry about the security of monetary transactions over the Internet/Web?
  
• Yes No