Tote Bags Order Form | beyondthediagnosis

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Tote Bag Order Form

Contact Information:

First Name*

Last Name*

Phone*

Email*

Shipping Address:

Address*

Address Line 2

City*

State*

Zip / Postal Code*

Product Information:

Product*

Tote Bag$26.99

Flat Rate Shipping Cost

$4.75

Child's Name*

Child's Disease*

Additional Comments

Your order is not complete until payment is submitted on the next screen.

After clicking “Proceed to Checkout,” please enter your payment information and wait for the order confirmation.

Proudly Supported By:

Beyond the Diagnosis

P.O. Box 16534 Rumford, RI 02916

Call me with confidence using Rogervoice captioned calls, a free US FCC-certified app

C: 401-487-3012

E: info@beyondthediagnosis.org

This program and exhibit are proprietary to Beyond the Diagnosis. Any reproduction of any portion of this program and exhibit are expressly prohibited without permission of Beyond the Diagnosis.

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