This request is for AANP's complimentary Opioid-Induced Constipation patient education tool (flipchart). Please ensure all fields are correctly filled out paying specific attention to the mailing address and your name.  This information will be used to complete the mailing label and any errors may delay the arrival of the flipchart(s).  

Please allow 6-8 weeks for delivery of the flipchart. 
 
We collect your email address in the event we need to contact you about the shipment. Furthermore, approximately 3-6 months after you receive the material we will contact you to get your feedback on the flipchart and accompanying tear sheets.  We use this feedback to guide us in the creation of future patient education tools and we appreciate your input. 

First name

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* 1. First name

Last name

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* 2. Last name

What is your mailing address? (Where the flipchart will be mailed)

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* 4. What is your mailing address? (Where the flipchart will be mailed)

City

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* 5. City

State

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* 6. State

Zip code

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* 7. Zip code

Email address

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* 8. Email address

If you would like more than one flip chart tool package, please re-login to the
survey and repeat the required information for each additional flip chart
package request. Thank you.

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