Chronic Disease/Health Promotion Materials Order Form

Chronic Disease Materials Order Form

INSTRUCTIONS: Complete the sections below to let us know where to ship your order and enter the quantity for each item requested. Orders will be fulfilled based on availability of items and is at the discretion of VDH staff.

Name*
First Last
Phone Number*
Fax Number
Email*
Organization Name*
Address (VA ONLY! No PO Box Address)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Special Shipping Instructions
Reason for request*
Date items needed*
MM slash DD slash YYYY
If Other, explain here
Stroke Materials
Stroke Smart Virginia Magnets- English
Comes with a display case that contains 50 magnets per holder with a limit of 10 (500).
Stroke Smart Virginia Magnets- Spanish
Comes with a display case that contains 50 magnets per holder with a limit of 10 (500).
Stroke Smart Wallet Cards- English
Comes with a display case contains 100 wallet cards. Order limited to 10 wallet cards cases (1000 wallet cards) If you want to print their own with city or hospital name let us know and can help.
Stroke Smart Wallet Cards- Spanish
Comes with a display case contains 100 wallet cards. Order limited to 10 wallet cards cases (1000 wallet cards) If you want to print their own with city or hospital name let us know and can help.
How do you plan to use them?
Want to join the VSSTF working group
Link?
Heart Disease and Stroke
Blood Pressure Ministry Toolkits - Item Number: WHA-15091, Resource to provide guidance and education to a congregation for a BP screening event
Quantity
Million Hearts Blood Pressure Wallet Cards - Item Number: 3-1645386B1, Resource to activate the public to lead a heart healthy lifestyle
Quantity
Blood Pressure Brochures - Item Number: BPMBROC
Quantity

Chronic Disease Materials Order Form

Stroke Materials

Heart Disease and Stroke