M.D.    Mr.         Ms.        Ph.D. 
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               UNITED PARCEL SERVICE ADDRESS IF 
                 DIFFERENT THAN ABOVE

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UPS Address 2  
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Home Phone      Work Phone   FAX 


Do you collect Journal Publications? (offprints, extracts, bound volumes)  
 Yes      No


I collect the following Subjects (please check all that apply):

 Alchemy        			 Geriatrics              		 Nursing
 Alcoholism  				 German Medicine         		 Obstetrics & Gynecology
 Allergy        			 Hematology              		 Oncology
 Anatomy                		 Herbals                 		 Ophthalmology
 Ancient Medicine  			 Heredity                		 Osleriana
 Anesthesia              		 Art & Medicine  			 Orthopedics                 
 Autographs(Medical)    		 History of Medicine    		 Pathology
 Aviation Medicine        		 Homeopathy              		 Pathology
 Bacteriology           		 Hospitals               		 Pediatrics
 Bibliography(Medical)		 Hydrotherapy          		 Pharmacology
 Biochemistry           		 Immunology             		 Phrenology
 Biology                		 Infectious Disease      		 Physiology
 British Medicine       		 Italian Medicine        		 Plastic Surgery
 Canadian Medicine      		 Jews & Medicine         		 Postcards(Hospital)
 Cardiology            		 Johns Hopkins           		 Psychiatry
 Chemistry              		 Legal Medicine          		 Public Health
 Climatology            		 Literature & Medicine		 Quackery
 Dentistry              		 Medical Biography       		 Radiology
 Dermatology            		 Medical Botany    			 Rheumatology
 Diabetes               		 Medical Education       		 Sexology
 Diagnosis              		 Medical Ephemera        		 Social Medicine
 Education              		 Medical Ethics          		 Specialization
 Embryology             		 Medicine                		 Sports Medicine
 Engraved Portraits     		 Medicine & Numismatics  		 Surgery
 Engravings(Medical)    		 Mesmerism               		 Syphilis & Other STDs
 Epidemiology           		 Microbiology            		 Thoracic Surgery
 Eugenics               		 Microscopy              		 Trade Cards(Medical)
 Evolution              		 Military Medicine       		 Transplantation
 Famous Patients        		 Music & Medicine       	 	 Tropical Medicine
 Fevers                 		 Natural History         		 Urology
 Folk Medicine          		 Nephrology              		 Vaccination
 French Medicine        		 Neurology               		 Virology
 Gastroenterology       		 Neurosurgery            		 Water Cure
 Genetics               		 Nobel Prize Winners			 Women & Medicine
                          

If your interests are not on this list, please enter them here:	I collect the following authors:
I would like to buy the following books: (Please provide author, title, place and date of publication, and any other specific information you would like us to have about the title(s) you are seeking)
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