Galactosemia Module & Wallet Card Order Form

Product Price Qty Subtotal

Galactosemia: $10.00 ______ ______
The Diet (New)
Galactosemia: $10.00 ______ ______
School Age
Children (New)
Galactosemia: $10.00 ______ ______
For New Parents
(New)

Cookbook $5.00 ______ ______

Activity Book $5.00 ______ ______

Ingredient Wallet $1.00 ______ ______

Card- Acceptable

Ingredient Wallet $1.00 ______ ______

Card- Unacceptable

Set of 3 New $25.00 ______ ______

Modules with
Wallet Cards
Set of All 5 $32.00 ______ ______
Modules with
Subtotal: _________ Purchasing and Contact Information for Questions:
Wallet Cards Michelle Stegall, Dietetic Technician
S&H: $4.00 *;
No S&H Charge for Wallet Card Only Orders Michelle.stegall@childrenscolorado.org
International Orders May be Subject to Increased Laurie Bernstein, MS, RD, FADA
S&H Fees; Please Inquire Prior to Ordering* Laurie.bernstein@childrenscolorado.org
Total: ________ Clinic Fax: 720-777-7322
Send Order to: Mail Order Forms to:
Name: ________________________ Children’s Hospital Colorado
Address: _______________________ Clinical Genetics and Metabolism
City: _________________ 13123 E 16th Ave B153
State: _________________ Aurora, CO 80045
Zip Code: __________ Please make checks payable to:
Country: _______________ IMD Clinic- Children’s Hospital Colorado
Telephone: ________________ Note: There is a $25.00 charge for all
Our Website is Accessible at the Link Below: returned checks
http://www.ucdenver.edu/academics/colleges/medicalschool/departments/pediatrics/subs/genetics/clinical/IMD
Nutrition/Pages/IMDNutritionHome.aspx