M.D.    Mr.         Ms.        Ph.D. 
Your Name      
EMail          
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Address Line 2 
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               UNITED PARCEL SERVICE ADDRESS IF 
                 DIFFERENT THAN ABOVE

UPS Address 1  
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                 Orthopedics
 Anesthesia
 Art & Medicine          Hernia                   Osleriana
 Autographs(Medical)     History of Medicine      Pathology
 Aviation Medicine       Homeopathy               Pediatrics
 Bacteriology            Hospitals                Pharmacology
 Bibliography(Medical)   Hydrotherapy             Phrenology
 Biochemistry            Immunology               Physiology
 Biology                 Infectious Disease       Plastic Surgery
 British Medicine        Italian Medicine         Postcards(Hospital)
 Canadian Medicine       Jews & Medicine          Psychiatry
 Cardiology              Johns Hopkins            Public Health
 Chemistry               Legal Medicine           Quackery
 Climatology             Literature & Medicine    Radiology
 Dentistry               Medical Biography        Rheumatology
 Dermatology             Medical Botany           Sexology
 Diabetes                Medical Education        Social Medicine
 Diagnosis               Medical Ephemera         Specialization
 Education               Medical Ethics           Sports Medicine
 Embryology              Medicine                 Surgery
 Engraved Portraits      Medicine & Numismatics   Syphilis & Other STDs
 Engravings(Medical)     Mesmerism                Thoracic Surgery
 Epidemiology            Microbiology             Trade Cards(Medical)
 Eugenics                Microscopy               Transplantation
 Evolution               Military Medicine        Tropical Medicine
 Famous Patients         Music & Medicine         Urology
 Fevers                  Natural History          Vaccination
 Folk Medicine           Nephrology               Virology
 French Medicine         Neurology                Water Cure
 Gastroenterology        Neurosurgery             Women & Medicine
 Genetics                Nobel Prize Winners