<p> Community Wellness Program for People with Parkinson’s Disease Manual Order Form</p><p>Institution name: Contact name: Contact phone number: Contact address: Contact email: Contact fax: </p><p>Anticipated first date of group: Anticipated end date of group: Number of participants: Number of manuals needed: </p><p>Do you need a copy of the outcome measures packet? Will your program include a speech component? </p><p>Please fax this order form to (617) 358-5460, or e-mail [email protected]</p><p>FOR OFFICE USE ONLY Order number: ______</p><p>Date order received: Date contacted to send Outcome Measures: Date order was shipped: Date Outcome Measures received: Shipping amount:</p><p>Date order information given to Lena: Date payment received: </p><p>____Check when entered into shadow spreadsheet</p><p>Billing: Manual total: Shipping total:</p><p>Total balance due: </p>