DADE Materials Order Form

Patient Anticholinergic Worksheet (Print-ready pdf)

English, with IPRO logo

Spanish, with IPRO logo

English, with your organizational logo*

Spanish, with your organizational logo*

Estimated number of recipients

Patient Anticholinergic Worksheet (Hard copy format)

English, with IPRO logo

Spanish, with IPRO logo

Number requested (Max 250 per order)

Prescriber Guide (Print-ready pdf)

With IPRO logo

With your organizational logo*

Estimated number of recipients

Prescriber Guide (Hard copy format)

With IPRO logo

Number requested (Max 50 per order)

DADE Literature Reference List (Print-ready pdf)

With IPRO logo

Estimated number of recipients

Boilerplate Text for Organization's Newsletters/Web Page (approximate 250 words, MS Word files)

For prescribers

For pharmacists

For patient/Family members

Your Name

Your Organization

Please choose one from this list that best describes your organization type

Your Organization's Address

City

State

Zip Code

Telephone of Contact Person

E-mail of Contact Person

Material Usage Agreement

Our organization agrees that, with the exception of adding our organization's logo to the documents, the content of these documents will not to be altered in any way.

More information

Orders for materials in print-ready pdf format:

Please provide us with estimated number of recipients of these documents.

* Orders for material in print-ready pdf format containing your organizational logo:

Please email your organization's logo to Susan Ulmer, sulmer@nyqio.sdps.org, in any one of the following formats: eps (vector) format or high resolution bmp, jpg or tiff.

Request for print-ready pdfs: Please be sure to enter the correct e-mail address to ensure timely delivery of these materials.
Request for printed materials: Please be sure to enter the correct mailing address for your organization to ensure timely delivery of these materials.

For more information, or if you have any queries, relating to this DADE Materials Online Order Form, please contact Susan Ulmer, sulmer@nyqio.sdps.org.

P4P: A Survey of State Medicaid Directors and Programs

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