Order Form

The Neuropsychology Center provides Halstead-Reitan Neuropsychological Battery equipment and materials for use in neuropsychological practice and research. These materials are to be used in accordance with APA Ethical Principles and the Standards for Educational and Psychological Testing.

Please print and complete this Order Form. If this is your first order with The Neuropsychology Center, please also complete the Customer Qualification Form. Fax, mail or email the completed form(s) to:

The Neuropsychology Center 9400 N Central Expy, Ste 904 Dallas, TX 75231-5049

Phone: 214-373-3607 Fax: 214-373-0762 Email: HRB@neuropsych.com

Once we receive your completed Order Form, we will calculate total cost including S/H and any applicable taxes. We will then send you an email with order confirmation and payment instructions for your final approval.

Name: _____________________________________________________ Customer #: ___________________

Address: _________________________________________________________________________________

City/State/Zip: _____________________________________________________________________________

Telephone: (_____)____________ Fax: (_____)____________ Email: ________________________________

Items I wish to order:

Item	Description	Qty	Price	Amount
Comments/Special Instructions:			Total

Planned method of payment: ___ Visa, MC, Discover ___ Check/Money Order

Signature:

I certify that all testing materials purchased from The Neuropsychology Center will be used in accordance with APA Ethical Principles and the Standards for Educational and Psychological Testing. I agree to the Terms and Conditions for the purchase and use of these items.

Signature: _______________________________________________ Date: _______________________

Name (printed): ________________________________________________________________________