KIDMED Materials Request Form

KIDMED 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:

	Materials	Quantity
	KIDMED Brochure
	CommunityCARE Brochure
	Posters for your Office
	CommunityCARE Reminder Cards

SHIPPING INFORMATION: (*Required Information)

*Name
Organization
*Address
Address Line 2
*City
*State
*Zip Code
Phone
E-Mail 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)