2010 Colorado Breast Cancer Resources Directory Order Form

Resources Directory Order Form

Order Date:
Quantity:	English Spanish
ALL THE INFORMATION BELOW IS REQUIRED:
Ship To Name:
Title:
Dept:
Business / Org: (Please provide business name if using business address)
Address:
City:
State:
Zip Code:
Phone:
Email:
Organization Website (URL):

Send orders by clicking the Submit Form button or you can
send orders by email or fax to:
Colorado Cancer Coalition
info@breastcancercolorado.org
303.691.7721(fax)

303-692.2331 (phone)

Your tax-deductible donation for the Directories may be made payable and sent to:
Colorado Cancer Coalition, c/o CFPHE, 9457 S. University Bl., #513, Highlands Ranch, CO 80126
Thank you!

In what ways is the Directory valuable to you? (Check all that apply.)
	It gives me answers to my questions.
	It shows me which resources are available if I need them.
	It gives me something to share with friends who may need the resources in the book.
	It gives me a way to support patients with information they may need.
	It lets my patients know about resources available if they need them.
	It lets my clients know about my services.
	Other:
If you distribute the Directory, in what ways do you distribute it? (Check all that apply.)
	Give it to patients when diagnosed.
	Give it to all patients when they ask for it.
	Have it on display and available for patients and others to take as needed.
	Provide it to medical staff.
	Distribute it at health fairs and other public meetings.
	Other:
What additional information should be in the next Directory?