Please check one VAX-D Lumbar Only VAX-D Lumbar with Cervical

• This order form is for a 24-page VAX-D Patient Brochure. It is an 8.5”x11” magazine style booklet. Call or email for a hard copy sample—contact info is at top right of page.

• Payment is due within 48 hours of going to press. We will notify you of this date. • Brochures ship 2–3 weeks after printing. Brochures come shrink-wrapped in 25-count bundles.

STEP 2: FILL OUT INFO BELOW

STEP 1:

Page 1October 2018 MW website order form. Copyright MediaWest 2005–2018. All Rights Reserved. File Name: Order Form Media West-Custom VAX v34

STEP 3: See Page 3

VAX-D Custom Order Form: 24 Page Brochure

Phone: 702-948-0633 • Fax: 702-446-8397Toll Free: 877-968-8631 • orders@mediawestpublications.com

Return this page via fax to: 702-446-8397

Product Description Qty Unit Price Total Price

Custom Black Ink 24-Page Brochures—Front and Back Cover Only: Order minimum is 500. Custom contact info in black ink is placed in designated area on back page. Front page doctor quote may be replaced with either a patient or doctor quote or contact info/logo. On the form below, choose Plate Change Fee Option 1 + Design Fee Option 1.

Custom Full-Color 24-Page Brochures—Front and Back Cover Only: Order minimum is 1000. Custom contact info in full color is placed in designated area on back page. Front page doctor quote may be replaced with your own and choice of image on front page. On the form below, choose Plate Change Fee Option 2 + Design Fee Option 1. If you also want to customize page 21, add Plate Change Fee Option 3 + Design Fee Option 2.

500+ 24-Page Custom Brochure (Cover Only - Black Ink order minimum is 500) 2.00

1000+ 24-Page Custom Brochure (Cover Only - Full Color order minimum is 1000) 1.90

1500+ 24-Page Custom Brochure (Cover Only) 1.80

2000+ 24-Page Custom Brochure (Cover Only) 1.70

Plate Change Fee Option 1: Black Ink (single plate)—front and back page 200.00

Plate Change Fee Option 2: Full-Color (4 plates)—front and back page 450.00

Plate Change Fee Option 3: Full-Color (4 plates )—page 21 only, must also select Option 50.00

Design Fee Option 1: Front and/or back page 99.00

Design Fee Option 2: Page 21 (must also select Design Fee Option 1) 199.00

Custom Full-Color 24-Page Brochures—Front and Back Covers + Inner Pages Quote Boxes: Order minimum is 2500. Custom contact info in full color is placed in designated area on back page. Front page doctor quote may be replaced with your own and choice of image on front page. Quote boxes on pages 2 and 4 and all of page 21 can be replaced with your own patient statements and pictures. Additional pages require additional design fee. See page 4 of order form for more details.

2500+ 24-Page Custom Brochure (Cover + Inner Pages - order minimum is 2500) 2.00

3000+ 24-Page Custom Brochure (Cover + Inner Pages) 1.90

3500+ 24-Page Custom Brochure (Cover + Inner Pages) 1.80

4000+ 24-Page Custom Brochure (Cover + Inner Pages) 1.70

Full Color Customization Fee - Front/Back Covers + Quotes on pages 2,3, 4 299.00

10% Off First Order (Applied to subtotal, before shipping. Does not apply to customization fees.)

Subtotal

SHIPPING WILL BE CALCULATED BY MEDIA WEST. 24-page brochures are sent via FEDEX Ground Shipping(1 to 5 business days). The cost will be what FEDEX Ground charges from the West Coast to your location. Cost is approximately $75 to $150 per 500 24-page brochures, depending on your location.

Custom orders are non-cancellable. All sales are final. Total

STEP 2: FILL OUT INFO BELOW

Page 2October 2018 MW website order form. Copyright MediaWest 2005–2018. All Rights Reserved. File Name: Order Form Media West-Custom VAX v34

• This order form is for a 4-page VAX-D Patient Brochure. It is made from one 11”x17” sheet folded in half to make four 8.5”x11” pages. Call or email for a hard copy sample—contact info at top right of page.

• One half of the cost of order is due immediately prior to printing.

• Second half just before shipping. These two charges occur 10-14 days apart.

• 4-page brochures come shrink-wrapped in 100-count bundles.

• Black Ink Custom Brochures: 2500 Minimum. Custom contact info in black ink is placed in designated area on back page (more info on page 5 of order form). Front page doctor quote may be replaced with either a patient or doctor quote or contact info/logo.

• Full-Color Custom Brochures: 5000 Minimum. Custom contact info in full color is placed in designated area on back page. Front page doctor quote, may also be replaced with custom full color info. Yellow patient statement boxes throughout may be replaced with your own doctor or patient statements (more info on page 5).

Planning On Doing A Mailer?If so, you’ll love our print & fold option.

(Available for custom orders only.)For just $25 (per 2500), you can have your 4-Page brochures mechanically folded in half (fits in a 6” x 9” envelope), or in thirds (fits in a 4¼” x 9” envelope).

Order the Folding Option Here Example of mailers in window envelopes (envelopes available at www.uline.com)

Please check one VAX-D Lumbar Only VAX-D Lumbar with CervicalSTEP 1:

STEP 3: See Page 3

VAX-D Custom Order Form: 4 Page Brochure

Phone: 702-948-0633 • Fax: 702-446-8397Toll Free: 877-968-8631 • orders@mediawestpublications.com

Return this page via fax to: 702-446-8397

Product Description Qty Unit Price Total

2500+ 4-Page Black Ink Only Custom Brochure — Minimum 2500 .43

Add your own patient statements on page 2 and 4 99.00

Add your own choice of image on front and full color contact info 99.00

5000+ 4-Page Full Color Custom Brochure — Minimum 5000 .39

Please fold my brochure: _____ in half _____ in thirds (Check One) 25.00 per 2500

10% Off First Order (Does not apply to shipping, folding, or special design fees.)

Subtotal

SHIPPING WILL BE CALCULATED BY MEDIA WEST. 4-page brochures are sent via FEDEX Ground Shipping(takes 1 to 5 business days). The cost will be what FEDEX Ground charges from the West Coast to your location. Cost is approximately $50 to $100 per 2500 4-page brochures, depending on your location.

Please Note: Custom orders are non-cancellable. All sales final. Total

Folded in thirds Folded in half

Octo

ber 2018 M

W w

ebsite o

rder fo

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op

yrigh

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iaWest 2005–2018. A

ll Rig

hts Reserved

. File Nam

e: Order Form

Media W

est-Custom

VAX

v34

1.) Fron

t Co

ver Cu

stom

ization

sFo

r Full C

olo

r Job

s: Current doctor quote m

ay be rep

laced with your D

r. Photo & Q

uote, Patient Photo &

Statement, or sim

ply Your Logo and C

ontact Info. All in full color. D

imensions of quote

box m

ay be changed to b

etter suit the content within. Statem

ents may need to b

e edited for length and clarity.

For B

lack Ink Jo

bs: C

urrent doctor quote may b

e replaced w

ith your own D

r. Photo & Q

uote, Patient statem

ent, or simp

ly Your Logo and Contact Info, all in b

lack ink (black ink does allow

for shades of grey). D

imensions of quote b

ox cannot be changed. Statem

ents may need to b

e edited for length and clarity.

PLEA

SE NO

TE: Size and

shap

e of q

uo

te box varies slig

htly d

epen

din

g o

n cover.

Wh

at Can

I Cu

stom

ize on

the Fro

nt C

over?

Pag

e 3

If Purch

asing

a Full-C

olo

r Cu

stom

ization

, Please C

ho

ose any C

over. D

efault C

overs (labeled

below

) are used

for B

lack Ink C

usto

mizatio

ns.

Bro

chu

re Co

ver Op

tion

s. Please C

heck O

ne.

Note: Lum

bar O

nly Covers w

ill say “Do You Suff

er from C

hronic Low Back Pain?”

Cover 1: Female 1 _____

Cover 2: Female, 2 _____

Cover 3: Male 1 _____

Cover 4: Female 3 _____

Cover 5: Male 2 _____

Default C

over for 24-Page Lumb

ar-Cervical

Default C

over for 24-Page Lumb

ar-Only

Retu

rn th

is pag

e via fax to: 7

02

-44

6-8

39

7

38954 Procto

r Blvd

, #158 • Sand

y, OR

97055Ph

on

e: 702-948-0633 • Fax: 702-446-8397To

ll Free: 877-968-8631 • ord

ers@m

ediaw

estpu

blicatio

ns.co

m

Default C

over for 4-Page Lum

bar-C

ervicalD

efault Cover for

4-Page Lumb

ar-Only

ST

EP

3:

For Fu

ll Co

lor Jo

bs:

Page 21 co

ntain

s a d

octo

r q

uo

te an

d 3

patien

t q

uo

tes. Th

ese q

uo

tes m

ay b

e rep

laced

with

you

r ow

n

patien

t an

d/o

r do

ctor state-

men

ts and

ph

oto

s. Statem

ents w

ill be

edited

if necessary

to fit in

the d

esig-

nated

space.

The

top

h

eadlin

e, “Resto

ring

Q

ual-

ity of Life” can

be

chan

ged

to

so

me-

thin

g

specific

to yo

ur p

ractice.

Do

es No

t Ap

ply to

B

lack Ink Jo

bs

This page applies to BOTH

Lumbar-O

nly and Lumbar Cervical Brochures

Pag

e 4

38954 Procto

r Blvd

, #158 • Sand

y, OR

97055Ph

on

e: 702-948-0633 • Fax: 702-446-8397To

ll Free: 877-968-8631 • ord

ers@m

ediaw

estpu

blicatio

ns.co

m

Octo

ber 2018 M

W w

ebsite o

rder fo

rm. C

op

yrigh

t Med

iaWest 2005–2018. A

ll Rig

hts Reserved

. File Nam

e: Order Form

Media W

est-Custom

VAX

v34

Wh

at you

get w

ith B

ack Co

ver C

usto

mizatio

ns fo

r the 24-P

age B

roch

ure

Wh

at you

get w

ith P

age 21

Cu

stom

ization

for th

e 24-Pag

e Bro

chu

re(Available for Full Color Custom

izations Only)

For Fu

ll Co

lor Jo

bs:

This blank sp

ace may b

e filled with w

ith your full color contact info, logo, slogan, doctor and/or p

atient statement.

For B

lack Ink Jo

bs:

This blank sp

ace may b

e filled with w

ith b

lack contact info, logo, slogan, etc.

For Fu

ll Co

lor Jo

bs O

nly:

The peach quote b

ox may b

e replaced w

ith your own p

atient or doctor statem

ent. Statements w

ill be edited if necessary to fit in

the designated space.

Lum

bar-C

ervical Back C

over

Lum

bar-O

nly B

ack Co

ver

For Fu

ll Co

lor Jo

bs:

A.) The p

each quote box on p

age 2 may b

e replaced w

ith your own p

atient or doctor statem

ent. Statements w

ill be edited if necessary to fit in the desig-

nated space.

Do

es No

t Ap

ply to

Black In

k Job

s

A

This page applies to BOTH

Lumbar-O

nly and Lumbar Cervical Brochures

Pag

e 5

For Fu

ll Co

lor Jo

bs:

This blank sp

ace may b

e filled with w

ith your full color contact info, logo, slogan, etc.

For B

lack Ink Jo

bs:

This blank sp

ace may b

e filled with w

ith black contact info, logo,

slogan, etc. You may p

ut doctor quote from front on the b

ack, and your contact info on the front in the sp

ace of the quote box.

38954 Procto

r Blvd

, #158 • Sand

y, OR

97055Ph

on

e: 702-948-0633 • Fax: 702-446-8397To

ll Free: 877-968-8631 • ord

ers@m

ediaw

estpu

blicatio

ns.co

m

Octo

ber 2018 M

W w

ebsite o

rder fo

rm. C

op

yrigh

t Med

iaWest 2005–2018. A

ll Rig

hts Reserved

. File Nam

e: Order Form

Media W

est-Custom

VAX

v34

Wh

at you

get w

ith B

ack Co

ver C

usto

mizatio

ns fo

r the 4-P

age B

roch

ure

Wh

at you

get w

ith In

side P

age

Cu

stom

ization

s for th

e 4-Pag

e Bro

chu

re

1.) High Resolution Logo: Logos must be at least 900 pixels wide (for a horizontal logo) or 900 pixels tall (for a vertical logo). Logos are accepted in the following formats: JPEG, TIFF, EPS, PDF, vector, or Illustrator vec-tor. Logos pulled from the web are too small. If you do not have a print-quality logo, but like your current logo, we offer logo re-creations 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.) Statements and Photos: If you’d like to use any of your doctor or patient statements and photos for the front cover, back cover, page 4 for the 24-page brochure, or page 2 in the four page, please send the quotes and photos to orders@mediawestpublications.com. We encourage all doctors to obtain and keep on file signed release forms for all patient statements and photos.

3.) For Full Color Customizations: Please see page 3 and check which cover you’d like.

4.) Information to Be Used In Custom Brochure Space:

Signature Required. Please Sign BelowI, the undersigned, understand that this order is non-cancellable and non-refundable. All custom orders are final.

Signature

Print Name and Professional Title

Date

Checklist of Things We Need From You

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):

Company Slogan (If applicable):

Page 6October 2018 MW website order form. Copyright MediaWest 2005–2018. All Rights Reserved. File Name: Order Form Media West-Custom VAX v34

Please send logos and statements to orders@mediawestpublications.com

Return this page via fax to: 702-446-8397

Custom orders are non-cancellable. All

sales final.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:Billing Address is same as shipping: ________

Billing Address: ________________________________________________________________________________

City: _____________________________________________ State: ________ Zip Code: ___________________

Billing Telephone: ( ) __________ – ______________

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? ______________________________________________________________

Page 7October 2018 MW website order form. Copyright MediaWest 2005–2018. All Rights Reserved. File Name: Order Form Media West-Custom VAX v34

Return this page via fax to: 702-446-8397 • Please print all information neatly.

This space is for office use only.

38954 Proctor Blvd, #158 • Sandy, OR 97055Phone: 702-948-0633 • Fax: 702-446-8397

Toll Free: 877-968-8631 • orders@mediawestpublications.com