Lab Coat Order Form

Name: ____________________________________________________

Sex:   Male ______   Female ______

Size (Please circle):   32   34   36   38   40   42   44   46   48   50   52

You may print and fax this page to the GME Office at 202-994-1604. All orders for returning residents and fellows must be received by June 15. The format for embroidering your name will be Dr. First Initial and Last Name. “Resident” or “Fellow” will appear under your name. There will be no departmental designations.

Name to be embroidered on your coat. PLEASE PRINT CLEARLY.

DR. ______________________________________________________

           First Initial            Last Name

Please provide your beeper number and email address in case there are questions regarding your order.

Beeper: ____________________________________

Email: ____________________________________