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NYS DOH EMS Pediatric Products Request Form
State EMS Form Number
EMS Agency Name
EMS Agency Code
Contact Information
Requester Full Name
Email
Phone
Mailing Address (No P.O. Boxes)
Address
Address 2
City/Town
State/Province
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American Samoa
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Armed Forces Pacific
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Tennessee
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Washington
West Virginia
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ZIP/Postal Code
Which Products Are You Requesting?
New York State Pediatric Assessment Reference Card (Publicaton #4157)
New York State Pediatric Badge Buddy (Publication #4185)
Both of the Above
New York State Pediatric De-Escalation (Publication #4189)
All Three Publications
Which Products are You Requesting? (Check as many that apply)
New York State Pediatric Assessment Reference Card (Publication #4157)
New York State Pediatric Badge Buddy (Publication #4185)
New York State Pediatric De-Escalation (Publication #4189)
Number of Pediatric Assessment Reference Cards Requested:
Number of Pediatric Badge Buddy Requested:
Number of New York State Pediatric De-Escalation Pamphlets
Number of Pediatric Assessment Reference Cards
Number of Pediatric Badge Buddy Requested
Number of NYS Pediatric De-Escalation Pamphlets
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