Custom Brochure Order Form
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File Name: Order-Form-Media-West-Custom-12-web.pdf
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Custom Brochure Order FormThis document contains a total of SEVEN pages, includingthis page. Be sure to read and fill out the information onthe following pages. Thanks! Page 1 2756 N Green Valley Parkway, #267 Henderson, NV 89014 Phone: 702-948-0633 • Fax: 702-446-8397 Toll Free: 877-968-8631 • [email protected] Custom Brochure Order Form Non-Surgical Spinal Decompression Patient Brochures (8.5”x11”) Return via fax to: 702-446-8397 or Call: 877-968-8631 Please check one option: Lumbar Only Lumbar with Cervical One half of the cost of order is due immediately prior to printing. Second half just before shipping. These two charges occur approximately 2-3 weeks apart
24-PAGE BROCHURE IS AVAILABLE IN INCREMENTS OF 25 SHRINK-WRAPPED BROCHURES Product Description Quantity Unit Price Total Price 500+ 24-Page Custom Brochure (Black Ink - 500 is minimum order) 2.00 1000+ 24-Page Custom Brochure (Full Color - 1000 is minimum order) 1.90 1500+ 24-Page Custom Brochure 1.80 2000+ 24-Page Custom Brochure 1.70 2500+ 24-Page Custom Brochure 1.60 3000+ 24-Page Custom Brochure 1.50 Black Ink Customization for 24-Page Front/Back Covers 150.00* Full-Color Customization for 24-Page Front/Back Covers 400.00* 4-PAGE BROCHURE IS AVAILABLE IN INCREMENTS OF 100 SHRINK-WRAPPED BROCHURES Product Description Quantity Unit Price Total Price 2500+ 4-Page Black Ink Only Custom Brochure .39 5000+ 4-Page Black Ink Only Custom Brochure .35 5000+ 4-Page Full Color Custom Brochure .39 10,000+ 4-Page Full Color Custom Brochure .35 10% Off First Order (applied to subtotal, before shipping. Does not apply to customization charge
Subtotal **(FEDEX ground charges) — Shipping Total* Additional design fees may be incurred, if client requests special customizations. Call for details
**Shipping will be added. It is what FEDEX Ground charges from U.S. West Coast to your location
Depending on your location, shipping is approximately $12 to $27 per box of 150 24-pagers and $6to $17 per box of 500 4-pagers
Page 2 September, 2009 MW website order form 2756 N Green Valley Parkway, #267 Henderson, NV 89014 Phone: 702-948-0633 • Fax: 702-446-8397 Toll Free: 877-968-8631 • [email protected] Please print all information neatly
FAX To: 702-446-8397 or Call: 877-968-8631 SHIPPING AND CONTACT INFORMATION:Company: _____________________________________________________________________________Contact Name: _________________________________________________________________________Mailing Address: ________________________________________________________________________City: __________________________________________ State: _________ Zip Code: ________________Telephone: ( ) ________ – ____________ Fax: ( ) ________ – ____________Email: ________________________________________________________________________________Clinic Website Address (If applicable) _______________________________________________________How did you hear about us? ______________________________________________________________ CREDIT CARD PAYMENT INFORMATION: MasterCard _______ Visa _______ Discover _______ AMEX _______Credit Card Number: ____________________________________________________________________Exp Date: _________ Security Card Code (3 digit code on back. 3 or 4 digit code on front of AMEX) _______________Name on Card: _________________________________________________________________________________Your Billing Company Name, If Applicable: __________________________________________________________ BILLING ADDRESS FOR CREDIT CARD OR BANK CHECK: Billing Address is same as shipping: ________Billing Address: ________________________________________________________________________________City: _____________________________________________ State: ________ Zip Code: ___________________Billing Telephone: ( ) __________ – ______________ BANK CHECK PAYMENT INFORMATION:Account Type: ____Business Checking ____Personal Checking ____Business Savings ____Personal Savings9-Digit Bank Routing Number: ____________________________________________________________________Bank Account Number: _______________________________________________ Check #: ___________________Bank Name: ___________________________________________________________ Bank State: ______________Check Signer’s Name: ___________________________________________________________________________Check Signer’s Driver License #: _________________________________ Driver License State: ________________Name or Company Name on Check: _______________________________________________________ Page 3 2756 N Green Valley Parkway, #267 Henderson, NV 89014 Phone: 702-948-0633 • Fax: 702-446-8397 Toll Free: 877-968-8631 • [email protected] IMPORTANT: Please download and view the “Custom Cover Options” PDFs (one for EACH brochure you are going to have customized) from our website at www.mediawestpublications.com. Click on the “ORDER” tab in the navigation bar at the top of the page. From there you will have the option of down- loading one of four different “Custom Cover Options” PDFs — one for the 4-page Lumbar/Cervical, one for the 4-page Lumbar Only, one for the 24-page Lumbar/Cervical, and another for the 24-page Lumbar Only
Please download and look over the PDFs that correspond with the brochures you are having customized
These PDFs show you all of your cover options for each given brochure and gives you a visual of exactly what the custom order space looks like on your brochure
Customization Fees (None for 4-Page Customizations) For 24-page Black Ink Only Custom Orders: Cost is $150. Includes $100 Black Ink Plate Change Fee and a $50 graphic design fee. Your contact info, logo, any photos, etc. will be printed in BLACK INK ONLY on the FRONT AND/OR BACK in the designated space. Rest of brochure will be in full color. $50 design fee is waived for future re-orders
For 24-page Full Color Custom Orders: Cost is $400. Includes $350 4-Color Ink Plate Change Fee and a $50 graphic design fee. Your contact info, logo, any photos, etc. will be printed in FULL COLOR on the FRONT AND/ OR BACK within the designated spaces. The rest of brochure will be in full color also
Information to be Used In Custom Brochure Space: If the clinic information you would like printed on your custom brochures is different from your Shipping and Contact Information (page 3), please provide us with the relevant information below. All fields are optional. It really just depends on what you want to have on your brochure in relation to the custom space available
Please print all information neatly. FAX this page to: 702-446-8397 Clinic Name on Brochure: Doctor or other medical professional names, if any you would like listed: Clinic Address: City: State: Zip Code: Telephone: ( ) ________ – ____________ Fax: ( ) ________ – ____________ Second Clinic Address: City: State: Zip Code: Telephone: ( ) ________ – ____________ Fax: ( ) ________ – ____________ Clinic Website Address (If applicable):September, 2009 MW website order form Page 4 2756 N Green Valley Parkway, #267 Henderson, NV 89014 Phone: 702-948-0633 • Fax: 702-446-8397 Toll Free: 877-968-8631 • [email protected] List of Available Customizations Alternate Cover Choices For Full-Color Orders Only:The doctor testimonial on the front cover of all the brochures may be replaced with a doctor orpatient testimonial of your choosing, so long as it fits in the existing rectangular space available(see Custom Cover Options PDFs for more details). Please send your doctor or patient testimonialto [email protected] Keep in mind that quotes may be edited down to fit in inthe designated space
Doctor Replacement Quote for Front Cover Customizations: (Applies to both 24- and 4-Page Brochures, as well as Full Color and Black Ink Orders)The doctor testimonial on the front cover of all the brochures may be replaced with a doctor orpatient testimonial of your choosing, so long as it fits in the existing rectangular space available(see Custom Cover Options PDFs for more details). Please send your doctor or patient testimonialto [email protected] Keep in mind that quotes may be edited down to fit in thedesignated space
Back Cover Customizations Available for 24-Page Brochures Only:The back cover may be customized with any relevant clinic information or images you wish to use. Inaddition to your logo, address, and website address, you may include additional info such as a doctoror patient testimonial and photograph, description of clinic services, etc. We can design the layout foryour custom content on the back cover, or you may provide a design from a graphic designer you al-ready work with. Designs must fit within a space of 7.25 inches wide and 4.25 inches high. Please sendinformation or design to email address above. Designs must be in PDF, EPS, or TIFF format, and mustbe 300 dots per inch when at a size of 7.25 inches wide
Back Cover Customizations Available for 4-Page Brochures Only:Contact Info Box: This customizatin option is available for both Full-Color and Black Ink Customiza-tions. The blue outlined box in the bottom right of the back page may be customized to include yourcontact information
Yellow Quote Box Customizations: This customization option pertains to Full-Color 4-Page Cus-tomizations Only. The testimonials within the yellow box on the back cover and/or inside of the fourpage brochures may be replaced with your own patient or doctor testimonials
Order Minimums (See order form for details)24-Page Custom Brochures (Color & Black Ink): 500 is minimum order quantity for black ink. 1,000is minimum order for full color customization. Price per brochure decreases as order quantity increases
4-Page Black Ink Only Custom Brochures: Available order quantities: 2500 or 5000.*4-Page Full-Color Custom Brochures: Available order quantities: 5000 and 10,000.** For pricing on higher quantities of 10,000 and above, please call Media West
Page 5 2756 N Green Valley Parkway, #267 Henderson, NV 89014 Phone: 702-948-0633 • Fax: 702-446-8397 Toll Free: 877-968-8631 • [email protected] Checklist of Things We Need From You Please Return this page via fax to: 702-446-8397Please also send logos and testimonials to [email protected]1.) High Resolution Logo: Logos must be at 300 dots per inch and AT THE VERY LEAST 3 inches at its widest or tallest mea- surement. For example, if you have a horizontally long logo, please make sure it is at least 3 inches wide and 300 dots per inch, even if it is 1 inch in height. Logos are accepted in the following formats: JPEG, TIFF, EPS, PDF, vector, or Illustrator vector. Logos pulled from your web page are unfortunately too low of a quality to print. If you do not have a print-quality logo, but like your current logo design, we offer logo recreations beginning at $75 for quick and easy reproductions
We charge $50 per hour after the first hour. We also create original logos: $150 starting price for text-only logos, and $300 starting-price for illustrated logos. Each logo design comes with 3 rounds of revisions. Additional revisions come at a charge of $50 per hour
2.) Optional Doctor Replacement Quote for Front Cover: Please send the quotes to the email address above. We encourage all doctors to obtain and keep on file signed release forms for all patient testimonials
3.) For Full Color Customizations (24-Page and 4-Page): Let us know which front cover design you’d like to go with. See the Custom Cover Options PDFs for alternate cover op- tions. Please Check which cover you’d like for the following: Lumbar Only 24-page Brochure: Default Cover (Male, Full-Body, Black Shorts) ____ Alternate Cover – Female, Lower Back ____Alternate Cover – Male, Blue Background _____ Alternate Cover – Female, Black top, black shorts _____ Lumbar/Cervical 24-page Brochure:Default Cover (Male, Blue Background) ____ Alternate Cover – Female, Lower Back _____ Alternate Cover – Male, Blue Background _____ Alternate Cover – Female, Black top, black shorts _____ Lumbar Only 4-page Brochure:Default Cover (Female Lower Back, White Background) ____ Alternate Cover – Male, Full-Body, Black Shorts ____Alternate Cover – Male, Blue Background _____ Alternate Cover – Female, Black top, black shorts _____ Lumbar/Cervical 4-page Brochure: Default Cover (Female, Black top, black shorts) ____ Alternate Cover – Female, Lower Back _____Alternate Cover – Male, Full-Body, Black Shorts ____ Alternate Cover – Male, Blue Background _____4.) For 4-Page Full Color Customizations: Patient or Doctor Replacement Testimonials for Yellow Quote Boxes on Back and/or Inside Pages. Please send the quotes to the email address above. We encourage all doctors to obtain and keep on file signed release forms for all patient testimonials. Media West may edit these testimonials for clarity or space consideration
Page 6 2756 N Green Valley Parkway, #267 Henderson, NV 89014 Phone: 702-948-0633 • Fax: 702-446-8397 Toll Free: 877-968-8631 • [email protected] Refer us to your colleagues, and get credit towards your next order!Get Referral Credit! When someone you refer to us places an order of $145 or more, you geta credit towards your next order over $200. $25 credit when referrals order between $145–$399, and a $50credit when referrals order $400 or more. One referral credit per purchase. It’s our way of saying Thank You!If you want, you can give us a referral in the space provided below. We’ll send brochure samples in hardcopy orelectronic format to the clinic you name, and if they place an order of $145 or greater, a credit will be applied toyour next order. It’s that easy! You may also email any additional referrals to [email protected]
Your Name:Your Clinic Name:Phone:Email:Name of Referral:Referral Clinic Name:Referral Phone:Referral Email:Referral Address:City: State: Zip: Please print all information neatly
FAX this page to: 702-446-8397 Page 7
1000+ 24-Page Custom Brochure (Full Color - 1000 is minimum order) 1500+ 24-Page Custom Brochure 2000+ 24-Page Custom Brochure One half of the cost of order is due immediately prior to printing. Second half just before shipping. These two charges occur approximately 2-3 weeks apart. 150.00* 400.00* 2756 N Green Valley Parkway, #267
