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Celiac Sprue

Celiac Screening, April 28, 2001

Celiac Blood Screening Registration Form

Make a separate copy of this registration from and fill out for each person participating.

Send the completed registration forms to: GIG, 9525 S.W. 12th Dr., Portland, OR 97219
 
 

Do not send in the questionnaire form. You should bring it with you to the event.
 
 

Name:	____________________________________________________________________________
Address:	____________________________________________________________________________
	____________________________________________________________________________
	City: _____________________________________ State: ___________ Zip: _______________
Phone:	( ______ ) _______ - _________________
Total Enclosed:	$ ___________ ($15 per person )
	Would you like to be on our mailing list (Yes/No)? ___________
	Would you like to receive email about future events such as this? If so, please give us your email address: _____________________

If you have questions, call Jeanne at (503) 244-8224 or Joanne at (360) 695-5568.

For more information, go to http://www.drchar.com/c-event.html

This page last modified Feb. 17, 2001