Product Order Form  mail to:
 Provider House, Inc.
166 Lucan Way
Riverdale, Georgia  30274
Personal Data/Mailing & Shipping Address:            Type in your information and print form.          Print This Form
     
First Name                                                              Last Name
                          
Address                                                                                                        Apt # / Suite #
         
City                                                                            State               Zip
          
E-Mail                                                                Home/Cell Phone                                Work Phone  
          
Fax Phone                                                       Best time to contact you:
              

 Preferred method of contact (check all that apply):  
E-Mail          Mail          Phone           Fax
Product Selection:     Recovery / Treatment Databases & Forms

Product Name

 Item #: Reg. Price: Sale Price: Qty Total Price:  
Outpatient Recovery Residence/Shelter 2.0 DB1057 $199.99 $139.99 $
Online Bio-Psychosocial Assessment 1.0 DB1280 $189.99 $119.99 $  
 Recovery Residence/Shelter Forms 2.0 FM1057 $7.99 N/A $  
 Bio-Psychosocial Assessment Forms 1.0 FM1280 $9.99 N/A $  
Recognition Awards Certificates 2.0 DB1997 $89.99 N/A $  
Online Participation Certificates 2.0 DB1531     $  
Client Card File 2.0    DB1010 $39.99 N/A $  
             
      Subtotal:   $  
      Tax-GA: .07%   $  
S/H (per item) $3.95 $
             
      Total Amount:   $  






 

  

Please Complete one (1) form per Center or Person.

 Payment Method:  (no cash please)                        Make check or money order payable to:  Provider House        
Check      Money Order                       Payments must be made in advance to receive product(s). 
                                                                                  Please allow up to 2 weeks for delivery due to high volumes of orders.

                          Print This Form
 

 © 2006-2007  Provider House, Inc.
Riverdale, Georgia  30274