#PADPlanInAction Poster Mailer Form

Name of Practice *

Type of Practice

Contact Name *

First

Last

Email *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

If you would like a printed poster to display in your clinic, please let us know how many to send (limit 5 per clinic):

Would you like an electronic copy (PDF) of the PAD Awareness Poster sent to your email?

Would you like us to send patient brochures for PAD?

Yes
No

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