DVD AND STAINED GLASS CARDS ORDER FORM - RSD Canada

dVD AND STAINED GLASS CARDS ORDER FORM

"2 out of 3 patients see 3 or more doctors before a diagnosis."

CRPS DVD: Every doctor and health care professional must become aware of CRPS. Drs. Pollett, Rhydderch and Shulman discuss symptoms, diagnosis, treatment options and management. These excellent pain management physicians deal with CRPS in their medical practices. Learn more about

CRPS and educate your family., friends and the community.

QTY

Item

DVD SET ( 2 Discs)

DVD set ( 2 discs)

Cost Per DVD or Card SET

PARC MEMBERS: $25

plus S&H

NON-MEMBERS: $30

plus S&H

SET OF 8 STAINED GLASS

ART CARDS

$20

per set plus S&H

Amount (tax incl.)

ADD S&H Total Price

Canada: $2.00 USA : $4.00 PER DVD SET

Canada: $2.00 USA : $4.00 PER DVD SET

Canada $1.92 USA $3.40

Packet of 2 CARD SETS:

Canada $2.65 USA $4.40

*Please make cheque payable to PARC.

GRAND $ TOTAL

***PRINT CLEARLY PLEASE. Ship to: NAME:________________________________ ADDRESS:_______________________________________________________________________ CITY/PROV:__________________________________COUNTRY:______________________P.CODE/ZIP:________________________________ TEL/E-MAIL: _______________________________COMMENTS: _________________________________________________________________

***Please make cheque payable to PARC, PO Box 21026, St. Catharines, Ontario, Canada L2M 7X2.

We thank you for supporting PARC!

PO Box 21026 St. Catharines Ontario, Canada L2M 7X2

PARC MEMBERSHIP FORM

"About 40% are diagnosed early (0-3 mo.), when the success rate is highest."

Our RSD CANADA Survey finds doctors lacking in knowledge. Every doctor and health care professional must be aware of CRPS, how to recognize, diagnose and treat it. This is not happening yet. Since May 2005, PARC has been conducting public CRPS Information Nights. We plan more in

2010. Thank you for your support!

FREE POCKET CARD WITH NEW MEMBERSHIP

PARC MEMBERSHIP : NEW RENEWAL $ extra MEMBERSHIP DONATION OPTION 1: DELUXE $35 per year (PARC Alert, Support, Newsletter, Survivor Club, Self-Mgt. Program) OPTION 2: REGULAR $25 per year (Quarterly newsletter only) PLEASE PRINT: NAME: _____________________________ADDRESS:________________________________________________________________________

CITY/PROV: _________________________________P CODE : ___________COUNTRY: ___________________________________________

***Please make cheque payable to PARC, PO Box 21026, St. Catharines, Ontario, Canada L2M 7X2.

WAYS TO HELP "About 66% see three or more doctors before a diagnosis."

PO Box 21026 St. Catharines Ontario, Canada L2M 7X2

Each doctor and health care professional must become aware of CRPS, how to recognize, diagnose and treat it. Early diagnosis is critical and often missed. With your help, PARC can educate

professionals through education programs. PARC also supports research into better treatments and a cure for CRPS. Proceeds will go towards PARC's educational programs and research at McGill University, Montreal. Please donate what you can towards our goals.

GIVE WHAT YOU CAN: I wish to make a donation to PARC. $1,000 $500 $250 $100 $50 $25 other _______ (Tax receipt issued for $10 and over.) PARC POCKET CARDS: I wish to receive CARDS x $ 2 each = TOTAL $ _______

PRINT CLEARLY PLEASE. Please send tax receipt to: NAME :________________________________ADDRESS:_______________________________________________________________________

CITY/PROV: __________________________________P. CODE:_________COUNTRY:______________________________________________

Please make cheque payable to PARC, PO Box 21026, St. Catharines, Ontario, Canada L2M 7X2.

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