*THIS FORM IS BEING RETIRED.* Orders placed through this form after 12/31/17 will not be filled. To access the current order form please visit our website at http://lymphedematreatmentact.org/increase-awareness/
Lymphedema Treatment Act Information Card Request Form

We only ship to US addresses. To receive an electronic file for either card please email us at info@LymphedemaTreatmentAct.org. Pictures of each card can be seen at http://lymphedematreatmentact.org/increase-awareness/. Thank you for spreading awareness!

Your First and Last Name *
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Company (if applicable)
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Street Address *
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City *
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State *
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Zip code *
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Number of Packs of Small Cards (they are a business card size and shrink wrapped in packs of 50 - orders over 6 packs will be verified before shipping - enter zero if you do not want any in this size) *
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Number of Packs of Large Cards (they are 4"x9" and shrink wrapped in packs of 50 - orders over 6 packs will be verified before shipping - enter zero if you do not want any in this size) *
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Your Email Address (in case we have any questions or problems filling your order) *
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