Set Request
Please fill out this form if you would like to receive or donate a Chemocessories gift set. (If you would like to DONATE a gift to a friend or family member please consider a DONATION that will help cover postage and some of our supplies. Click here to DONATE: http://chemocessories.org/donate.html) Please make sure you fill out all of the required information requested. Thank you. BECAUSE OF OUR DEMAND AND INVENTORY IT MAY TAKE UP TO 12 WEEKS TO RECEIVE A SET. Sets are one of a kind.
Recipient's First Name *
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Recipient's Last Name *
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Donor First & Last Name (complete if you are *not* the recipient)
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Recipient's Email *
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Recipient's Street Address *
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Recipient's City *
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Recipient's State - ALL CAPS *
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Recipient's Zip Code *
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Recipient's Earring Preference *
Recipient's Age Range
Recipient's Color Preference
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At what medical facility is the recipient receiving treatment? *
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Add a message for the recipient
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How did you find out about us? *
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Add a comment for Chemocessories
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Are you the recipient? *
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