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Tell Us Your Story

Thank you for your decision to share your heart story with us. We ask that you please take a few minutes of your time to give us a little information about yourself along with submitting your story.

Name:
Address:
City: State: Zip:
Email Address:

Daytime Phone: Evening Phone:
Date of Birth:
Month Day Year
Sex: Female Male
Number of Children in household: Age 5 or under Age 6-11 Age 12- 17
Do you have a primary care doctor in town? Yes No
Please check your health plan: Medical Mutual of Ohio Other


I would like Mercy HealthLink to refer me to a:
Cardiac Specialist Family Doctor OB/Gynecologist Pediatrician
Other Specialty
Best time to call: a.m. p.m.(be sure to include your phone numbers above.)

Would you like more information from Mercy Health Partners on the following:
Women's Health
Women's Heart Care
Life Saving Tests for Women
Breast Self Exam Shower Card
Health & Fitness
Fitness & Wellness Class Guide
Mercy Sports-Works
Cardiac Care
Healthy Heart Kit
Cardiac Risk Factors Guide		 Children's Health
Parent's Newsletter (HUGS)
Monster Deterrent Kit
(Night Light One per houshold)
Health Guides
Fast Food Nutrition Guide
Cancer Resource Guide
Emergency Guide		  
Please let us know if you would be comfortable receiving future health care communications (e.g. newsletters, preventive health information and classes) in the following formats. Our goal is to provide the information you desire in the format you prefer.
Regular Mail:
Yes No		 E-Mail:
Yes No

Please share with us your "Story from the Heart."



I grant permission to Mercy Health Partners to post my submission on mercyweb.org and allow my story to be used in other printed marketing materials. I understand that I may be contacted by Mercy Health Partners representatives if my story is selected for use in mass media, such as radio and print ads. I understand that all submissions will be reviewed by Mercy Health Partners and may be edited for content.
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© 2008 Catholic Healthcare Partners
Last Modified 9/29/2008