ORDER FORM

Please print out and send with your cheque to:

The Old Operating Theatre, Museum and Herb Garret

9a St. Thomas's Street

London SE1 9RY

Please send me 1 copy/___ copies of THE APOTHECARY PACK (price £5.00)

I enclose a cheque for £_____ payable to: The Lord Brock Memorial Trust.

Name: ____________________________________________

Address: ________________________________________________________________

Address: ________________________________________________________________

How did you hear about the Pack? _______________________________________________

MAILING LIST: tick as required: ____

Please add me to the museum's emailing list:

Email address: ___________________________________________________________

Please add me to the museum's postal mailing list:

Address if different from above: _______________________________________________

Address: __________________________________________________________________________