CodingToday Bundling Matrix Only Purchase

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Subscription Type

Bundling Matrix Only Annual

$159

User Information

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	Salutation
	Professional Title
	First name		*
	Last Name		*
	Suffix

	Email Address		* This will also be your user name.


	Password		*
	Confirm Password		*

Payment Information

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	Card Type
	Number		*
	Expiration		* / * MM/YYYY
	Name on Card		*

Referral Program

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Contact and Shipping Information

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	Street Address		*
	Unit
	City		*
	State		*
	Postal Code		*
	Phone		x
	Fax

Practice Information

	Practice Name
	Specialty
	Locality

Billing Information

Required fields are marked with an asterisk. The billing address MUST match the address on your credit card statement. If your billing information is the same as your contact information, simply check the box below. You do not need to complete this portion of the form again.

Use shipping address as billing address

	Salutation
	Professional Title
	First name		*
	Last Name		*
	Suffix

	Email Address		*

	Phone		x
	Fax

	Street Address		*
	Unit
	City		*
	State		*
	Postal Code		*