Materials Request Form

The Healthy Start Coalition of Miami-Dade is pleased to be able to provide you with materials we know you will find useful as you help to promote good pregnancy outcomes and healthy babies. If you are in need of educational materials, please take a moment and fill out our Material Request Form. HSCMD reserves the right to limit requested quantities. 

You may download the  Materials Request Form for Community 06 08 2016 by clicking below and submit via fax: (305) 541-0213 or e-mail: hscmdoutreach@hscmd.org 

Materials Request Form for Community 06 08 2016


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1 Step 1
Basic Information

Requested by
Name of Organization or Practice/Facility
Phone Number
Address(i.e. Street, Suite # (if applicable), City, State, Zip)
Event/Purpose
Event Date
date_range
Instructions:

Healthy Start Risk Screen

Quantity (RS - 1st Pack)
Quantity (RS - 2nd Pack)
Quantity (RS - 3rd Pack)
Quantity (RS - 4th Pack)
Quantity (RS - 5th Pack)

HSCMD Education Library Brochures (25/Pack)

Quantity (ELB - 1st Pack)
Quantity (ELB - 2nd Pack)
Quantity (ELB - 3rd Pack)
Quantity (ELB - 4th Pack)
Quantity (ELB - 5th Pack)
Quantity (ELB - 6th Pack)
Quantity (ELB - 7th Pack)
Quantity (ELB - 8th Pack)
Quantity (ELB - 9th Pack)
Quantity (ELB - 10th Pack)

HSCMD Educational Library Info-Cards (25/pack)

Quantity (ELIC - 1st Pack)
Quantity (ELIC - 2nd Pack)
Quantity (ELIC - 3rd Pack)
Quantity (ELIC - 4th Pack)
Quantity (ELIC - 5th Pack)
Quantity (ELIC - 6th Pack)
Quantity (ELIC - 7th Pack)
Quantity (ELIC - 8th Pack)
Quantity (ELIC - 9th Pack)
Quantity (ELIC - 10th Pack)

Right from the Start Brochure & Info-Cards (25/pack)

Quantity (SBIC - 1st Pack)
Quantity (SBIC - 2nd Pack)
Quantity (SBIC - 3rd Pack)
Quantity (SBIC - 4th Pack)
Quantity (SBIC - 5th Pack)

Education (25/pack)

Quantity (Education - 1st Pack)
Quantity (Education - 2nd Pack)
Quantity (Education - 3rd Pack)
Quantity (Education - 4th Pack)
Quantity (Education - 5th Pack)

Other Educational Materials

Quantity (OEM - 1st Pack)
Quantity (OEM - 2nd Pack)
Quantity (OEM - 3rd Pack)
Quantity (OEM - 4th Pack)
Quantity (OEM - 5th Pack)
Quantity (OEM - 6th Pack)
Quantity (OEM - 7th Pack)
Quantity (OEM - 8th Pack)
Quantity (OEM - 9th Pack)
Quantity (OEM - 10th Pack)

Promotional Items (Available in limited quantities)

Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity
Quantity

Other

Other Materials (i.e. Condoms, Special Items, etc.)


Other 1
Quantity (Other 1)
Other 2
Quantity (Other 2)
Other 3
Quantity (Other 3)



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