Index/Order Form of Materials Please note - Pain Resource Center ...

CITY OF HOPE PAIN RESOURCE CENTERORDER FORMTotal number of materials:Total amount of order:Add $15.00 for orders mailed overnight:__________________________________________Please note: Please print each page where items are requested from the Index/Order Form and includewith the check and this ORDER FORM. There is a nominal $3.00 fee for ordering written materialsfrom the Index to help defer the cost of printing and mailing. We must receive payment with the order.We are unable to send an invoice, accept Purchase Orders or credit card charges. We are able to acceptpayment in U.S. currency only.Make check payable to:Mail check and order form to:City of HopeCity of Hope Pain Resource Centerc/o Nursing Research & Education1500 East Duarte RoadDuarte, CA 91010CUSTOMER INFORMATION (mailing address to receive materials)Name ___________________________________________________________________Institution __________________________________________________________________________Address ____________________________________________________________________________CityState _______ Zip Code ________________PhoneFor our Records:How did you hear about us?Ad in a journal/newsletterAt a conferenceReceived an index/order form in mailA colleagueInternet Search Other (list: )Profession:RN MD Social Work PharmacistPatient Family Member PT/OT Other (list: )Work setting:Hospital Hospice Home Care Clinic/OutpatientNursing Home/Long Term University Other (list: ___ )Web Site:1) Have you used the PRC website (http://prc.coh.org)? Yes No2) What was the most useful feature of the web site? Do you have any suggestions to enhance it?112