Advance Health Care Directive (AD) / Video/DVD Order Form

To make purchase using a credit card:

• Please call: 310-319-4189.
• Please Print This Page and FAX (310-319-4010).

Or purchase by check:

• Please Print This Page and mail with check (payable to "The UCLA Foundation/CHEC") and mail to:
• Poonam Bhatla
  The Center for Humane and Ethical Medical Care (CHEC√ )
  Santa Monica-UCLA Medical Center
  1250 16 th Street
  Santa Monica, CA 90404

Yes, I want to purchase a VHS copy of "Who Will Speak for Robert?"
DATE
FORMAT	DVD VHS Tape
AMOUNT	$30
PAYMENT	Check enclosed AMEX Credit Card Visa Credit Card Discover Credit Card MasterCard Other:
CARD NUMBER
EXPRIRATION DATE
SIGNATURE
NAME or DEPARTMENT
ORGANIZATION
ADDRESS
CITY, STATE, ZIP
PHONE
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