ENDOW
(Ethnicity, Needs, Decisions of Women)
Intervention Material One Line Order Form
The University of Alabama at Birmingham
1717 11th Ave South, MT 730
Birmingham, AL  35205
(V) 205-934-6383  (F) 205-934-7959 E-Mail: ENDOW@dopm.uab.edu

To purchase copies of ENDOW intervention materials listed below return this on-line order form and a check or money order made payable to the University of Alabama at Birmingham ENDOW project at the address above.


Please indicate below in box located next the language of choice the number of copies you would like to purchase.   The price of each ENDOW intervention material includes all shipping and handling charges for the US Post Office by First Class Mail.
 

"Hysterectomy: The Decision is Yours"

 

Cost

 

English Version

 

Spanish Version

Video:

$ 10.00 each

 Number of:

 Number of:

Brochures:

$ 1.00 each

 Number of:

 Number of:

 

 

 

 

 

 

"The Wise Woman's Guide to Making Decisions"

Booklets:

$ 5.00 each

Number of:

Number of:

 

 

 

 

 

 

"The Decision is Yours: Talking To Your Doctor"

Booklets:

$ 5.00 each

Number of:

Number of:

 

 

 

 

 

 

 


Please fill in all information
so that your order can be processed promptly and efficiently.

Thanks for your order

Name:  ______________________________________________________

Company: ____________________________________________________

Address: _____________________________________________________

_____________________________________________________________

City: _______________________ State:  _____ Zip Code:  ______________

Phone: __________________ Ext. ______________

E-mail: ______________________________________________________
 

Amount total included: _______________
 

 

To be filled out by ENDOW staff only.
 Date filled: _____________________
Comments: _____________________