Endocrine Clinic & Medical Professionals
Order form for Clinic Resource Packs & other materials
Section A: Your Contact Details
Contact Name
Prof / Dr / Mr / Mrs / Miss / Ms (Please circle)
Post Held/ Title:
Hospital/Clinic/Department/Practice:
Hospital/Delivery Point Address:
An order cannot be sent unless we have exact delivery address
Invoice to this address □
Work Telephone No:
E-Mail Address:
Invoice to this address □
Section B: Order a Clinic Resource Packs
The packs help clinics educate patients and can help patients self manage their condition.
The Pituitary Foundation is subsidising the resource packs for clinics so the booklets are heavily
discounted in comparison to ordering booklets separately.
STANDARD PACK £100 (£115 inc p&p)
 60 booklets of your choice from our range of publications
 2 endocrine referral pads (50 sheets per pad)
 5 information posters, including our new Adrenal Crisis leaflet
 1 Who We Are booklet - our general charity booklet
 2 Copies of our patient magazine Pituitary Life – 3 times a year
 Your hospital will be mentioned on our website as a clinic that stocks our extra support materials – this will last
for one year from purchase
 1 GP Factfile
 1 complimentary Hydrocortisone advice information leaflet, 1 Post pituitary surgery factsheet, 1 Factsheet for
A&E and hospital ward staff – Adrenal Insufficiency patient, 1 Factsheet for A&E and hospital ward staff –
Diabetes Insipidus patient, 1 Hydrocortisone factsheet for Ambulance Personnel, 1 Patient care card, 1 DI
awareness card, 1 Hydrocortisone awareness card, and 1 Toilet facilities card. (Useful to show patients who
can then order their own free from The Pituitary Foundation)
LARGE PACK £200 (£220 inc p&p)
 120 booklets of your choice from our range of publications
 4 endocrine referral pads (50 sheets per pad)
 10 information posters, including our new Adrenal Crisis leaflet
 1 Who We Are booklet - our general charity booklet
 4 copies of our patient magazine Pituitary Life – 3 times a year
 Your hospital will be mentioned on our website as a clinic that stocks our extra
support materials – this will be the case for one year from purchase
 2 GP Factfiles
 2 complimentary Hydrocortisone advice information leaflets, 1 Post pituitary surgery factsheet, 1 Factsheet for
A&E and hospital ward staff – Adrenal Insufficiency patient, 1 Factsheet for A&E and hospital ward staff –
Diabetes Insipidus patient, 1 Hydrocortisone factsheet for Ambulance Personnel, 2 Patient care cards, 2 DI
awareness cards, 2 Hydrocortisone awareness cards, and 2 Toilet facilities cards. (Useful to show patients who
can then order their own free from The Pituitary Foundation)
To order please tick below and fill in the booklet options form overleaf.
I would like to purchase a LARGE
clinic resource pack - £220 inc p&p
Please tick
□
I would like to purchase a STANDARD
clinic resource pack - £115 inc p&p
Please tick
□
Registered Charity No. 1058968
Company No. 3253584
Please turn over…
Please specify which booklets you would like your clinic resource pack to consist of. (60 booklets of
your choice included in a standard pack, 120 in a large pack.)
Amount
Ordered
Title
Acromegaly
Pituitary Patient Care Card
(sent for free with resource packs
already)
Adult Growth Hormone Factsheet
Pituitary Patient Handbook
Cushing’s
Pituitary Surgery & Radiotherapy
Diabetes Insipidus
Prolactinoma
Relationships & Communication:
with Yourself and with Others
The Pituitary Gland, Its Disorders
and Hormone Explained
The Psychological Impact of a
Pituitary Condition
Weight Control & Nutrition in Adults
with Pituitary Conditions
Your Journey: Living with and
Managing a Pituitary Condition
Employment
Hydrocortisone Advice for the Pituitary Parent
Hydrocortisone Advice for the Pituitary Patient
(sent for free with resource packs already)
Living with Infertility
Male Hormones & Infertility Issues
Amount
Ordered
Title
______________________________________________________________________________
Payment details (Please tick) Please invoice us at the address above □ Find enclosed a cheque for payment □
Alternatively, visit our online shop www.pituitary.org.uk to order using PayPal or debit/credit card – however if you pay
online, you will still need to fill in this clinic resource order form and email this to us to let us know which booklets you
would like.
Please tick if you would like us to set up a payment by account (invoicing for orders) through the website for you to use
next time you order from us
□
Section C: Separate FREE resources
We can provide clinics with the following useful resources free of charge (including free postage and packaging).
(Please note resource packs already include these items but you can order extra)
Publication
FREE Pituitary Foundation Referral Pad A5
(50 sheets per pad. Max per order 5)
Handy tear off sheets for clinics with information
for patients about the support services available
from The Pituitary Foundation
Amount
Required
Publication
Amount
Required
FREE A4 information
posters – 2 types
(Max per order 10).
Who We Are - our general
charity booklet
(Max 3 per order)
Need to place a smaller booklet order for less than 50 items?
If you would like to order a smaller amount of booklets, booklets are currently priced at £2.50 each. To order please do
so through our website shop, or email helpline@pituitary.org.uk or telephone - 0117 3701316 to be sent the correct
order form. We can send out an invoice with clinic orders. If your clinic requires over 50 booklets the resource
packs provide the best value for money.
We will contact you after one year to ask if you require another resource pack.
All of our publications are also published in full on our website and are free to download www.pituitary.org.uk
Please return this form to: The Pituitary Foundation, 86-88 Colston Street, Bristol, BS1 5BB
Please make all cheques payable to The Pituitary Foundation
Registered Charity No. 1058968
Company No. 3253584