chemo duck order form
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Required Field
hospital
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contact name
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city
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state/province
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zip code
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phone number
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email
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PORT
$23.00 each
Quantity
HICKMAN
$23.00 each
Quantity
IMPORTANT NOTICE: Please note the minimum combined order for chemo ducks is 12. If you are interested in a smaller quantity, please contact our office at (615) 830-0126 or lu@chemoduck.org for details about our Adopt-A-Duck program.
shipping information
company name
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attention
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address
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city
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state/province
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zip code
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phone number
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email
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initial here
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WAIVER: In placing this order, we understand that we are not alloed to solicit funds from families who recieve services or materials from Gabe's Chemo Duck program.
please select one of the following:
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We will be able to provide a donation/funding for the ducks ourselves.
We will be able to provide funding from a secondary source.
We will require assistance from Gabe's My Heart in identifying funding for our hospital.
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