DIVISION OF WOMEN’S AND INFANTS’ HEALTH

FAMILY PLANNING ORDER FORM

REQUESTED BY: / DATE:
TELEPHONE #: / FAX #:
COMPANY NAME:
STREET ADDRESS (NO P. O. BOX):
CITY/STATE/ZIP:
SPECIAL SHIPPING INSTRUCTIONS OR DUE DATE: / PHONE, MAIL OR FAX YOUR COMPLETED ORDER FORM TO:
Marketing Support Solutions, Inc.
Attn: Dina Crowder
P. O. Box 4248
Lynchburg, VA 24506
Phone: (434) 385-1900
Fax: (434) 385-4996
Toll Free: (800) 474-3928

COMPLETE THE SECTION ABOVE. WRITE THE QUANTITY OF EACH PUBLICATION THAT YOU NEED TO THE LEFT OF THE ITEM.

QUANTITY / ITEM # / DESCRIPTION
WIH-001 / ABOUT STDS (SEXUALLY TRANSMITTED DISEASES)
WIH-002 / ABOUT VAGINAL INFECTIONS
WIH-003 / HIV…WOMEN GET IT TOO
WIH-003S / HIV…WOMEN GET IT TOO (Spanish)
WIH-004 / ARE YOU UNDER 18?
WIH-005 / THE BIRTH CONTROL “SHOT” DEPO-PROVERA
WIH-007 / DEPO-PROVERA IMPORTANT INFORMATION CHECK SHEET
WIH-007S / DEPO-PROVERA IMPORTANT INFORMATION CHECK SHEET (Spanish)
WIH-008 / DEPO-PROVERA, PATIENT CARE INSTRUCTIONS
WIH-008S / DEPO-PROVERA, PATIENT CARE INSTRUCTIONS (Spanish)
WIH-009 / DIRECTORY OF LOCAL HEALTH DEPARTMENT CLINICS
WIH-010 / INFORMATION FOR WOMEN – Your Sterilization Operation
WIH-010S / INFORMATION FOR WOMEN – Your Sterilization Operation (Spanish)
WIH-011 / INFORMATION FOR MEN – Your Sterilization Operation
WIH-011S / INFORMATION FOR MEN – Your Sterilization Operation (Spanish)
WIH-012 / PRACTICE BIRTH CONTROL/ PLAN YOUR PREGNANCY CAREFULLY
WIH-012S / PRACTICE BIRTH CONTROL/ PLAN YOUR PREGNANCY CAREFULLY (Spanish)
WIH-013 / NATURAL FAMILY PLANNING
WIH-016 / SAYING NO TO SEX, IT MAKES SENSE
WIH-018 / WHAT MEN SHOULD KNOW ABOUT CONTRACEPTION
WIH-019 / GROWING UP FOR PRETEENS & YOUNG ADULTS
WIH-026A-S / GET THE “B” ATTUTUDE – FOLIC ACID (Spanish)
WIH-027 / SEXUAL COERICION…RECOGNIZE AND RESIST IT
WIH-027S / SEXUAL COERICION…RECOGNIZE AND RESIST IT (Spanish)
WIH-034 / MEN! HAVE YOU CONSIDERED A VASECTOMY?
WIH-036 / AVOIDING SEXUAL COERCION
WIH-036S / AVOIDING SEXUAL COERCION (Spanish)
GN-001S / WHY EVERY WOMAN NEEDS FOLIC ACID (Spanish)
WIC-059 / BABIES NEED FOLIC ACID EVEN BEFORE YOU KNOW YOUR PREGNANT – CARD (Order by # of packages 100/pkg)
WIC-060 / BABIES NEED FOLIC ACID EVEN BEFORE YOU KNOW YOUR PREGNANT – DISPLAY – (Spanish)
WIC-061 / BABIES NEED FOLIC ACID EVEN BEFORE YOU KNOW YOUR PREGNANT – CARD – (Spanish) (Order by # of packages 100/pkg)
FOL-04 / BROCHURE - FOLIC ACID: NOW YOU’RE TALKING HEALTHY (50/pkg.)
FOL-04S / BROCHURE – FOLIC ACID: NOW YOU’RE TALKING HEALTHY (50/pkg.) (Spanish)
FOL-05 / POSTER 11”x17” – FOLIC ACID: NOW YOU’RE TALKING HEALTHY (50/pkg.)
FOL-05S / POSTER 11”x17” – FOLIC ACID: NOW YOU’RE TALKING HEALTHY (50/pkg.) (Spanish)
FOL-06 / BOOK MARKS – FOLIC ACID: NOW YOU’RE TALKING HEALTHY (50/pkg.)
FOL-06S / BOOK MARKS – FOLIC ACID: NOW YOU’RE TALKING HEALTHY (50/pkg.) (Spanish)

PLEASE DO NOT SEND YOUR ORDER TO OUR OFFICE. ALL ORDERS MUST GO THROUGH

MARKETING SUPPORT SOLUTIONS, INC.

Revised April 2006