END-OF-LIFE CARE ORDER FORM

ONLINE ORDER FORM FOR THE END-OF-LIFE CARE SERIES

Please enter all information below and click the "Submit Order" button.
You will receive a confirmation of your order and we recommend that you print it for your records.

1) FORMAT:
Please choose program format (select one):				VHS Videotape		CD-ROM

2) SHIPPING INFORMATION:

Recipient's name:				Recipient's Title:

Institution name

Address:

City:			State:		Zip Code:

3) CONTACT INFORMATION:
Please provide contact information of purchaser (email is not a required field)
Contact Name:				Department:

Phone:				Email:

4) PAYMENT OPTIONS:
Please select an online payment method of either credit card or purchase order. If you use a PO# to purchase then a complete copy of the purchase order must be faxed or mailed before your order can be processed. Faxing and mailing information is available on the previous "how to order" page.

If paying by purchase order, please enter that order number here:

If paying by credit card, please complete the following:
		VISA		MASTERCARD		DISCOVER

Account number:					Exp. date:

Name on card:				Please charge card for this amount:

5) PROGRAMS:
By not completing the information below it is assumed that you are ordering the entire six-program End-of-Life Care series for $595.00. If you wish to only order individual programs from within the series for $125.00 each (S&H included), please select which title(s) you would like to receive by checking the boxes below.
I do not want to receive the entire six-program series at this time. Please send me the following programs at $125.00 each:
	Program One: What is End-of-Life Care				Program Four: Decision Making at End-of-Life
	Program Two: Providing Comfort Care				Program Five: Supporting the Family
	Program Three: Individualizing End-of-Life Care				Program Six: End-of-Life Issues Within & Across Settings

Please click the submit button only once.