Materials Request Form

Please fill out the form below to receive educational materials from the Indiana Poison Center.

Orders will be processed within three business days. Please allow time for processing and shipping.

For quantities over 200, please call (317) 962-2335.

"*" indicates required fields

Name*
MM slash DD slash YYYY
Address*
Reasons for Material*
Please enter a number from 0 to 200.
Please enter a number from 0 to 200.
Please enter a number from 0 to 200.
Please enter a number from 0 to 200.
Please enter a number from 0 to 200.
Please enter a number from 0 to 200.