Physician Materials Request Form

New Professional Members will receive one copy of each patient educational material offered, along with a form to order up to 12 bulk packs at no charge. The National Rosacea Society is also happy to send single copies of its materials to health professionals for free via the form below.

For bulk quantities, we request a tax-deductible donation of $10.00 per bulk pack of 25 to cover shipping and handling. The patient booklets can be previewed in their entirety within the Information for Patients section. Please call 847-382-8971 with questions about your order.

Materials Request Form

Please complete your contact and shipping information, then choose the materials and quantities you would like to receive below. To help cover handling and shipping expenses, we request a tax-deductible donation of $10.00 per standard bulk pack, payable via credit card.

Name
Address

Professional Membership

New members will receive one copy of each patient educational material offered, along with a form to order up to 12 bulk packs at no charge.

Patient Education Materials

Please select the materials and note the amounts you would like to receive by mail. The Society is happy to send single copies of its materials for free. For bulk quantities, we request a tax-deductible donation of $10.00 per bulk pack of 25 to cover shipping and handling, payable online via credit card.

Professional Materials

Please select the materials you would like to receive by mail. The Society is happy to send single copies of its materials for free.

0
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.