On-line Order Form

POISON PREVENTION GUIDE Alabama Poison Center On-line Order Form
The Alabama Poison Center is pleased to offer free Poison Prevention Guides to residents of Alabama. Our goal is to prevent accidental poisonings throughout the state. Ordering your Poison Prevention Guide is the place to start.
Order now by completing this on-line order form. It could save your life! Please allow 4 weeks for delivery. If you need your Poison Prevention Guide earlier, please contact Lois Dorough at 1-800-462-0800 or you can send an email to ldorough@alapoisoncenter.org.
First Name: *
Last Name: *
Address: *
Address:
City: *
State: *
Zip Code: *
Telephone Number:(include area code) *
Email Address:
How many Poison Prevention Guides do you need?
Indicate Number: *
How do you plan to use the Poison Prevention Guide(s)? Select all that apply.
Select All That Apply: *	Home Work School Other (Please Specify Below)
Please Specify 'Other':
Have you ever called the Alabama Poison Center before? *	Yes No
Privacy Statement: The above information will only be used to deliver your requested information, track distribution of poison prevention materials or the use of our services, and to plan ways to better meet your needs. The Alabama Poison Center does not release names submitted to any other group, and individual names will not be used on any report created by the Alabama Poison Center.
Enter the Code as it is shown: *
Click the SUBMIT button to send your information. Thank You.