END-OF-LIFE CARE ORDER FORM
     

(printable version)

      
1) FORMAT:
Please choose program format:      __ VHS Videotape      __ CD-ROM

2) SHIPPING INFORMATION:
Please print your shipping address for the programs:
 
Recipient's name:_______________________
 		 Recipient's title:___________________________
 
Institution name: ____________________________________________________________
 
Address: ____________________________________________________________________
 
City: _________________________________
 		 State:___________
 		 Zip Code:___________
 
3) CONTACT INFORMATION:
Please print primary contact person's information :
 
Contact name:_________________________
 		 Department:_______________________________
 
Phone:________________________________
 		 Email:____________________________________
 
4) PAYMENT OPTIONS (three choices):
 
____  Enclosed is a check, made out to Healthcare Management Television (HMTV),
          EIN 54-1694579, for $595 (shipping and handling included)
 
____  Please charge order to our (circle)    VISA     MASTERCARD      DISCOVER
 
  Account# ______________________________
 		 Exp. Date: ________________
 
  Signature:______________________________
 		 Name on card:_________________
 
  Please charge my credit card this amount: ______________________
 
____  Purchase Order Number:______________________ (please remember to include PO with order)
 
5) INDIVIDUAL PROGRAMS (if applicable):
I do not want the entire series of six programs for $595 but instead want to order the following programs for $125 each (S & H included):
 
____ l. What is End-of-Life Care? ____ lV. Decision Making at End-of-Life
____ ll. Providing Comfort Care ____ V. Supporting the Family
____ lll. Individualizing End-of-Life Care ____ Vl. End-of-Life Issues Within and Across Settings