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<title>Archives Photograph Order Form, Henry Ford Hospital, Detroit, MI</title>
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<body bgcolor="224A73" leftmargin="0" topmargin="0" marginwidth="0" marginheight="0"><!--~ Dynamic website caching for reduced server load and increased crawlability. --><!-- links to cached pages --><noscript><table width="100%" border="0" cellspacing="0" cellpadding="0"><tr><td align="right"><a href="http://www.henryfordhealth.org/125157.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a><a href="http://www.henryfordhealth.org/152378.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a><a href="http://www.henryfordhealth.org/19438.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a><a href="http://www.henryfordhealth.org/19147.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a><a href="http://www.henryfordhealth.org/1.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a><a href="http://www.henryfordhealth.org/101.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a><a href="http://www.henryfordhealth.org/19085.cfm"><img src="http://www.henryfordhealth.org/HenryFordHealthSystem3.GIF" border="0"></a></td></tr></table></noscript><!-- B henryfordhealth.org ~--><!-- body ok -->
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		<td style="border-collapse:collapse;margin:0;padding:0;vertical-align:top;"><a href="http://www.henryford.com/"><img src="images/2008/logo_clear_body.gif" border="0" alt="Henry Ford Health System"></a></td>
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		<table  background="" border="0" cellspacing="0" cellpadding="0">	<tr class=""  background="">		<td class="" valign="middle" align="center" background="" title=""><a href="http://www.henryford.com"  class="">Home</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/topnavline.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=48446"  class="">After Hours & Urgent Care</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/topnavline.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=45404"  class="">Hospitals</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/topnavline.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=37839"  class="">Medical Centers</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/topnavline.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=40194"  class="">Emergency Rooms</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/topnavline.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=38557"  class="">Pharmacies</a></td>	</tr></table>
	
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			<img src="images/arrowtop.gif">&nbsp;<a href="body_nologin.cfm?id=39330" class="breadcrumb">Patient&nbsp;Library</a>&#32;
			
			<img src="images/arrowtop.gif">&nbsp;<a href="body_nologin.cfm?id=39357" class="breadcrumb">Lam&nbsp;Archives&nbsp;&&nbsp;Hospital&nbsp;History</a>&#32;
			
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						<span class="pageName"><h1>Archives Photograph Order Form</h1></span>
						
							
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				<td class="metadetail" colspan="2">Use this form to request copies of photographs from the Conrad R. Lam Archives.&nbsp;&nbsp;&nbsp;Please specify <a href="http://www.henryford.com/body_nologin.cfm?id=39488">photo numbers</a>if available.<br><br>If you have any problems with this form, please send an email to <a href="mailto:sladenwebmaster@hfhs.org">Sladen Webmaster</a>.<br><br><br></td>
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				* Indicates required information</span></td>
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					<input type="Hidden" name="eformField_3_required" class="metadetail" value="Phone Number is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Email Address&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_4" class="metadetail" size="35" value="">
					  
					<input type="Hidden" name="eformField_4_email" class="metadetail" value="Email Address must be a valid email address.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Cost Center&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_5" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">What Do You Need?&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_6" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">What Will You Use If For?&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_7" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Number of Copies:&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_8" class="metadetail" size="35" value="">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Format:&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<nobr><input type="radio" name="eformField_9" id="eformField_9_1" style="{border:0;}" value="Color Print" checked>
					<label for="eformField_9_1" class="metadetail">Color Print</label></nobr><br>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_2" style="{border:0;}" value="Black & White Print">
					<label for="eformField_9_2" class="metadetail">Black & White Print</label></nobr><br>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_3" style="{border:0;}" value="Slide">
					<label for="eformField_9_3" class="metadetail">Slide</label></nobr><br>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Size:&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<nobr><input type="radio" name="eformField_10" id="eformField_10_1" style="{border:0;}" value="5x7&quot;" checked onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_1" class="metadetail">5x7"</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_10_1";
						//--></script>
					<nobr><input type="radio" name="eformField_10" id="eformField_10_2" style="{border:0;}" value="8x10&quot;" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_2" class="metadetail">8x10"</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_10_2";
						//--></script>
					<nobr><input type="radio" name="eformField_10" id="eformField_10_3" style="{border:0;}" value="11x14&quot;" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_3" class="metadetail">11x14"</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_10_3";
						//--></script>
					<nobr><input type="radio" name="eformField_10" id="eformField_10_4" style="{border:0;}" value="16x20&quot;" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_4" class="metadetail">16x20"</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_10_4";
						//--></script>
					<nobr><input type="radio" name="eformField_10" id="eformField_10_other" style="{border:0;}" value='Other' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_other" class="metadetail">Other</label></nobr><br>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" wrap="soft" name="eformField_10_other_txt" id="eformField_10_other_" disabled class="metadetail"></textarea>
						</p>
					</div>
					<script language="JavaScript" type="text/javascript"><!--
					smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_10_other";
					//--></script>
					<input type="hidden" name="eformField_10_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Finish:&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<nobr><input type="radio" name="eformField_11" id="eformField_11_1" style="{border:0;}" value="Matte" checked>
					<label for="eformField_11_1" class="metadetail">Matte</label></nobr><br>
					<nobr><input type="radio" name="eformField_11" id="eformField_11_2" style="{border:0;}" value="Glossy">
					<label for="eformField_11_2" class="metadetail">Glossy</label></nobr><br>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">When Do You Need It?&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<select name="eformField_12" id="eformField_12" class="metadetail">
						<option value="3 working days">3 working days</option>
						<option value="5 working days">5 working days</option>
						<option value="7 working days" selected>7 working days</option>
						<option value="10 working days">10 working days</option>
					</select>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">Normal turnaround time is 7 working days.  Rush service is available for a 100% rush charge.&nbsp;</th>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Method of Delivery:&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<nobr><input type="radio" name="eformField_14" id="eformField_14_1" style="{border:0;}" value="Pickup" checked>
					<label for="eformField_14_1" class="metadetail">Pickup</label></nobr><br>
					<nobr><input type="radio" name="eformField_14" id="eformField_14_2" style="{border:0;}" value="Interdepartmental Mail">
					<label for="eformField_14_2" class="metadetail">Interdepartmental Mail</label></nobr><br>
					<nobr><input type="radio" name="eformField_14" id="eformField_14_3" style="{border:0;}" value="U.S. Mail (Please specify your mailing address)">
					<label for="eformField_14_3" class="metadetail">U.S. Mail (Please specify your mailing address)</label></nobr><br>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Mailing Address&nbsp;</th>
				<td class="metadetail">
					<textarea name="eformField_15" class="metadetail" cols="40" rows="5"></textarea>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">Please contact Melanie Bazil at Lamarchives@hfhs.org or (313) 874-6948 for pricing information.&nbsp;</th>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">All work is done in-house by the HFHS Media Resources.&nbsp;</th>
			</tr>
			<tr class="metadetail">
				<th class="metadetail">&nbsp;</td>
				<td class="metadetail">
					<input type="submit" name="submit" value="Submit" class="metadetail">
				</td>
			</tr>
		</table>
		</form>
	
	
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	<br>1-800-HENRYFORD (800-436-7936)&nbsp;&nbsp;&nbsp;&nbsp;Copyright 1997 - 2010</td>
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