Please fill out this form and return here to the top and for an e-mail response or you may print it out and mail it to THE MEDIC at the address below. Send another form with just your name for estimates on more than three figures. You may need to

Your name: Please mail to:
THE MEDIC
P.O. Box 281
Buckner, KY 40010
Address:
City, ST, ZIP:
Telephone:
email address:

Patient Number 1:
Kung Fu Grip Life-Like Hair Talking Negro

What seems to be the trouble?

What services would you like THE MEDIC to provide?
Clean Remove Stain Repair Voice Box Paint Head
Restring Replace Joint(s) Install Pull Cord Reflock hair

Patient Number 2:
Kung Fu Grip Life-Like Hair Talking Negro

What seems to be the trouble?

What services would you like THE MEDIC to provide?
Clean Remove Stain Repair Voice Box Paint Head
Restring Replace Joint(s) Install Pull Cord Reflock hair

Patient Number 3:
Kung Fu Grip Life-Like Hair Talking Negro

What seems to be the trouble?

What services would you like THE MEDIC to provide?
Clean Remove Stain Repair Voice Box Paint Head
Restring Replace Joint(s) Install Pull Cord Reflock hair