Resource Order Form

Name *

Organization Name *

Mailing Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

How did you learn about this resource?

Other source

Resources

Enter the quantity for each resource you are requesting. Note that quantities may be limited. Some resources are available for download and may be printed locally.

	Quantity
Non-Occupational Post-Exposure Prophylaxis (nPEP) Provider Pocket Guide	Non-Occupational Post-Exposure Prophylaxis (nPEP) Provider Pocket Guide
nPEP Scroll Pen for Providers	nPEP Scroll Pen for Providers
nPEP Patient Assistance Program Postcard for Providers	nPEP Patient Assistance Program Postcard for Providers
HCV Screening and Treatment Flyer for Providers	HCV Screening and Treatment Flyer for Providers
Passport to Cure Brochure for Clients - English	Passport to Cure Brochure for Clients - English
Passport to Cure Brochure for Clients - Spanish	Passport to Cure Brochure for Clients - Spanish
Hep C Free Postcard for Clients - English	Hep C Free Postcard for Clients - English
Hep C Free Postcard for Clients - Spanish	Hep C Free Postcard for Clients - Spanish
HIV/HCV Co-infection: An AETC National Curriculum Postcard for Providers	HIV/HCV Co-infection: An AETC National Curriculum Postcard for Providers
HIV/HCV Co-infection Awareness Stethoscope Badge	HIV/HCV Co-infection Awareness Stethoscope Badge
HIV/HCV Co-infection Awareness Pin	HIV/HCV Co-infection Awareness Pin
AETC National HIV Curriculum Postcard for Providers	AETC National HIV Curriculum Postcard for Providers
AETC Program Postcard	AETC Program Postcard
NCCC Palmcard	NCCC Palmcard

What percentage of your patients living with or at risk of HIV: