Consumer Health Request Form

Date:
Name:
Address:
City:
State:
Zip:
Time:
Age:
Gender:
  • Male
  • Female
Phone:
Fax:
Email:
Room #:
How would you like to receive information?
  • Call me and I'll pick it up
  • Mail it to me at above address
  • Fax it to me at above number
  • Email it to me at above address
  • Deliver to room number above
Information is for:
  • Self
  • Friend/Family Member
  • Health professional to give to patient or family members
  • Other
Describe your request. So we can serve your needs better, please be as specific as possible about what you would like to know:
Name of disease/condition
What information is wanted (e.g. definition/cause/treatment/prognosis)
Check appropriate box (es) below:
  • Easy-to-understand information
  • More technical level of information
How did you find out about the Center?
  • Brochure
  • Health Professional
  • Friend or Relative
  • Patient T.V. Channel
  • Saw sign for Patient & Consumer Health Center
  • Saw sign for Health Sciences Library
  • Center’s Website
  • Other
In lieu of my signature, by submitting this form, I attest that the information submitted is accurate and correct.
© 2009-2012