 |  | | Print this form, fill it out, and fax it to 215-574-2225 or mail it to the address below out to start your subscription. |  |  |  |  | | Please fill in the name(s) of the collection(s) to which you wish to subscribe ($99 each, per year), or write an X next to the all of images.MD box to subscribe to the entire site for only $323 per year. |  | | First Collection | | Second Collection (optional) | | Third Collection (optional) | | | all of images.MD | |  |  | | Please note that you must provide a valid email address in order to receive your subscription. |  | | Name | | First | | M.I. | | Last | | Profession | | | Primary Medical Specialty or Interest | | | Secondary Medical Specialties or Interests (optional) | | | Email Address | | | check enclosed* | VISA | | Mastercard | American Express | | Circle one | | Number | | | Name on card | | Exp. Date | | | Signature | |  | | *Please make all checks payable to Current Medicine Group LLC, in U.S. funds only. | Current Medicine Group LLC 400 Market Street, Suite 700 Philadelphia, PA 19106 United States of America |  | |