• Unfortunately this order form is not interactive yet. Because of the high cost of a secure connection, we do not expect to offer interactive ordering in the near furute. Instead, you may print it or use it as a reference when calling, faxing, or e-mailing us.

The following is a list of educational materials and products available from A.L.E.R.T., Inc.
Indicate the quantity next to the suggested donation of items you would like to receive. Enclose this order form with your check or money order payable to A.L.E.R.T., Inc. in U.S. dollars and mail to:

American Latex Allergy Association
A.L.E.R.T., Inc.
PO BOX 13930
MILWAUKEE, WI 53213-0930

For imformation or to place a credit card order, contact us by phone or e-mail:

Toll Free: (888) 97 ALERT
      Fax: (414) 677-2808
   e-mail: alert@execpc.com

We can send an order form (Microsoft Word format) as an e-mail attachment, or through snail mail as needed.
(Please allow 3-4 weeks for delivery of ordered items.)

Item/ Description:	Unit Donation:	Quantity:	Total:
Guidelines for the Emergency Care of the Latex Allergic Patient (EMS Manual)	$54.00
Information for the EMS systems / Emergency Rooms for a safer rescue.
School Education Packet:	$14.00
Information on natural rubber latex allergy for schools. Contains a school list.
Hospital Packet	$25.00
Information on how to set up a task force and policies. Contains a hospital list.
Patient Packet	$15.00
Information on natural rubber latex allergy for the individual. Contains a home list.
Product Lists: Alternatives Note: Although these lists are available on-line, we encourage purchasing a physical copy for reference.
Hospital	$5.00
Home	$5.00
Dental	$5.00
School	$5.00
Latex Warning Sticker	$4.00
For home and vehicle windows. Comes with a press release to educate your local fire department on latex allergy and an adhesive warning sticker
Emergency Pouch	$12.00
For purse or vehicle. Contains a patient protocol, non-latex tourniquet, 2 pairs of non latex gloves and 2 latex warning stickers: one for use in your vehicle window and the other to put on the clear side of the pouch. The pouch contains room for other medical items supplied by the user, such as an EpiPen, inhaler, or blister packet or prescription tablets.
Patient Protocol	$4.00
Brochure	$0.25
Contains the symptoms of latex allergy, information for people diagnosed with latex allergy, the goals of A.L.E.R.T., Inc. and an application for membership. (Bulk discout available)
2" Round Sticker	$0.60
A.L.E.R.T., Inc. logo with the words "no natural rubber latex" across the circle. These plastic coated stickers can be removed from plastic or metal. Ideal for patient charts. (Bulk discount available)
4" Square Sticker	$0.80
Ideal for use on solidwood doors, chart folders, crash carts, for labeling cabinets containing no natural rubber latex. These plastic coated stickers can be removed from plastic and metal.
Latex Allergy Bibliography	$25.00
122 selected articles on various topics relating to latex allergy.
Membership and Newsletter	$25.00
Annual membership includes the newsletter, published quarterly.
Additional Donation:
Total U.S. Dollars Enclosed:

       Name:    _____________________________________________

       Address: _____________________________________________

                _____________________________________________

City/State/Zip: _____________________________________________

         Phone: _______________________