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Welcome, Please, fill out, print, and fax the form below to 416 536-6700. If you experience any problems, please, give me a call -- 416 538-7839 (10 - 6pm EST) or e-mail to marcia@moonland.com. Thank you. Marcia

Payment by Fax

Please fill in the following personal information (Make sure to type your email address correctly):
Name:
Email:
Please fill in the following information about your child:
Child's Name
Age:
Sex :	Male Female
A short history of the progression of your child's illness (3-5 sentences): A brief account of all the tests performed to diagnose your child's condition and the results of those tests: A short but detailed description of all of those symptoms that belong to the condition you want us to treat.
payment information (* required fields)
*Amount of payment in U.S. dollars	$15 $20 $25 other
*Patient's name
*Your name if different from above
credit card information
*Cardholder's name as it appears on the card:
*Card number:
*Expiry date:
billing address for this card :
* Your name if different from the cardholder's name
* Address line 1 (or company name)
a Address line 2 (optional)
* City
* Province or Region
* Country
* Postal or Zip Code

 

 

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