Juvenile Arthritis Medications CD Order Form

The Medication Resource CD is designed to allow you to easily move through the module to the areas that are of interest. You will find interviews with parents, children, and medical staff along with resource and documents for your use. If you would be interested in receiving a free copy of the Medication CED please click on the link listed below complete the form and submit your request. The Great Lakes Region of the Arthritis Foundation supports families who face the challenges of arthritis and related diseases; we are here to help you.
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Contact 
Contact Information
First Name:*
Last Name:*
Email:*
Address Line 1:*
Address Line 2:
City:*
State:*
ZIP/Postal Code:*
Phone:
Child's Name:*
What is your child's diagnosis?:
Child's Birth Date:*(mm/dd/yyyy)
Child's Name:*
Date of Diagnosis:(mm/dd/yyyy)
Name of Child's Pediatric Rheumatologist:
Child's gender:* Male
Female
        

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