CommunityCARE Materials Request Form

To ensure an accurate and timely order please completely fill out the following shipping information and press the SUBMIT button.
Special requests or handling should be noted in the Comments section.

NOTE: Please contact Jose Villa at 1-800-359-2122 for assistance in planning Health Fair Events.
Also, please remember that all PCP materials provided by Providers must be pre-approved by DHH.

MATERIALS REQUEST:

	KIDMED Brochure		Quantity Requested
	CommunityCARE Brochure		Quantity Requested
	Posters for Your Office Brochure		Quantity Requested
	CommunityCARE Reminders Cards		Quantity Requested

*SHIPPING INFORMATION: (=required information)**
*Name:
Organization:
*Address:
Address Line 2:
*City:
*State:
*Zip Code:
Phone:
*Email Address:
Place Event in News & Events Section?	Yes No
Comments:

To order the following Health Fair items, please contact Jose Villa at 1-800-359-2122:

Doctor Headbands	Nurse Hats
Immunization Record Cards	Pencils
Chip Clips	Crayons & Coloring Books
Band-aid Dispenser	Refrigerator Magnets
Balloons	Cups (KIDMED)