FOR CHILDREN WITH CEREBRAL PALSY

Your Smile: Dental Care for Children with Cerebral Palsy

VIDEO ORDER FORM

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Directions:

  1. Fill out the following form to receive your free dental video.

  2. Print out the completed form.

  3. Mail it along with a check in the amount of $5.00*, per video requested, payable to:
    HMS School for Children with Cerebral Palsy
    4400 Baltimore Ave.
    Philadelphia, PA 19104
    *Fee covers cost of shipping and handling.

Name:
Title:
Company:
Address:

City/State/Zip:
Telephone:
Fax:
Quantity:
Amount Encl.:

If you have questions or need additional information regarding the video, please call us at:
1-215-222-2566

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