Community Wellness Program for People with Parkinson S Disease

Community Wellness Program for People with Parkinson’s Disease Manual Order Form

Institution name: Contact name: Contact phone number: Contact address: Contact email: Contact fax:

Anticipated first date of group: Anticipated end date of group: Number of participants: Number of manuals needed:

Do you need a copy of the outcome measures packet? Will your program include a speech component?

Please fax this order form to (617) 358-5460, or e-mail [email protected]

FOR OFFICE USE ONLY Order number: ______

Date order received: Date contacted to send Outcome Measures: Date order was shipped: Date Outcome Measures received: Shipping amount:

Date order information given to Lena: Date payment received:

____Check when entered into shadow spreadsheet

Billing: Manual total: Shipping total:

Total balance due: