Kimberly-Clark* Disney® Child's Face Mask Sample Order Form

Please fill in the information below and Kimberly-Clark will send you the Disney® Child's Face Mask sample you request.
Date: 7/4/2009
Contact Information
*First Name: *Last Name: *Facility: *Title: Central Supply/Central Service Dental Emergency Department Emergency Services Engineering Laboratory Industrial Hygiene Materials Management/Purchasing Nurse Educator Perioperative Nurse Quality Improvement Respiratory Therapy Risk Management Surgeon Other Other: *Email: *Phone:   Your email address and phone are needed if we need to contact you regarding your order. It will not be used for solicitation. *Address: Address: *City: *State: *Zip:
Ship Sample To:	Same As Above
*Facility: *Attention: *Address: Address: *City: *State: *Zip: *Phone:
Would you like to receive electronic updates on healthcare topics from Kimberly-Clark?  Yes No If Yes, which particular fields are you most interested in (check all that apply)? Surgical Issues Sterilization Issues Glove Related Issues Medical Device Issues Infection Control Issues Managerial Issues Would you be willing to participate in online market research regarding healthcare topics?  Yes No