Index/Order Form of Materials Please note - Pain Resource Center ...
Index/Order Form of Materials Please note - Pain Resource Center ...
Index/Order Form of Materials Please note - Pain Resource Center ...
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CITY OF HOPE PAIN RESOURCE CENTERORDER FORMTotal number <strong>of</strong> materials:Total amount <strong>of</strong> order:Add $15.00 for orders mailed overnight:__________________________________________<strong>Please</strong> <strong>note</strong>: <strong>Please</strong> print each page where items are requested from the <strong>Index</strong>/<strong>Order</strong> <strong>Form</strong> and includewith the check and this ORDER FORM. There is a nominal $3.00 fee for ordering written materialsfrom the <strong>Index</strong> to help defer the cost <strong>of</strong> printing and mailing. We must receive payment with the order.We are unable to send an invoice, accept Purchase <strong>Order</strong>s 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 <strong>of</strong> HopeCity <strong>of</strong> Hope <strong>Pain</strong> <strong>Resource</strong> <strong>Center</strong>c/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: )Pr<strong>of</strong>ession: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 <strong>of</strong> the web site? Do you have any suggestions to enhance it?112