Print Guide Order Form

The bold fields are required.

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Use for the guide:   Self Parent Family Business

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Contact Information

First Name:

Last Name:

Company:

Email Address:

Address:

Address (con'd):

City:

Province/State: --Select-- Alberta British Columbia Manitoba New Brunswick Newfoundland Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Québec Saskatchewan Yukon Territory Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Country: --Select-- Canada United States

Postal Code/Zip:

Phone:

This is my: Home Work Mobile phone number.

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How Did You Hear About The Care Guide?

Newspaper Ad
Internet Search
The Care Guide (print version)
Association (eg. ORCA, OLTCA)
CCAC/Regional Health Authority
Hospital/Discharge Planner
Other (please specify below)

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Quantity

Please enter the quantity you require for each region:

	Alberta (Chinook, Palliser, Calgary, David Thompson, East Central, Capital, Aspen, Peace Country & Northern Lights Health Regions)
	British Columbia (Vancouver Island, Vancouver Coastal, Fraser, Northern, & Interior Health Regions)
	South Central Ontario (Greater Toronto Area, Simcoe County, Hamilton-Wentworth, Niagara Region & surrounding areas)
	South Western Ontario (Brantford, Kitchener-Waterloo, Orangeville, Owen Sound, London, Sarnia, Windsor & surrounding areas)
	North Eastern Ontario (Peterborough, Kingston, Ottawa, Muskokas, Kawarthas, North Bay, Sudbury, S.S. Marie, Thunder Bay & surrounding areas)

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Preferred City

Please enter your preferred cities:

Preferred City #1: 

Preferred City #2: 

Preferred City #3: 

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YES, I would like to have my contact information made available to providers in my area who may be able to help and send me information about their services.