Only Virginia schools participating in the mouthrinse program
can order mouthrinse supplies.

Date:

Name of School & City/County:

Number of Children Swishing:

Your Name:

Phone Number:

10ml (20 mg)

5 ml (10 mg)

Flavor

# Cases needed

Flavor

# Cases needed

Bubblegum

Bubblegum

Grape

Mint

Orange

Root Beer

Unflavored

Ship to: (need street address for shipping)

If you prefer, you may download this order form as a .pdf document (requires Adobe Reader), complete it, then fax it to: Sharon Logue, 804-864-7783.

• Before placing your order, please read these guidelines
  FMP guidelines 2008
• Supply Order Form

Contact Sharon R. Logue, R.D.H., M.P.H.
109 Governor St., 9th flr., Richmond, VA 23219
Phone: (804) 864-7778• FAX: (804) 864-7783