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<title>Wyandotte Hospital Library Information Request 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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		<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;
			
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			<img src="images/arrowtop.gif">&nbsp;<a href="body_nologin.cfm?id=52236" class="breadcrumb">Wyandotte&nbsp;Hospital&nbsp;Library&nbsp;Information&nbsp;Request&nbsp;Form</a>&#32;
			
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						<span class="pageName"><h1>Wyandotte Hospital Library Information Request Form</h1></span>
						
							
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				<td class="metadetail" colspan="2">Consumer / patient health information is sent free of charge to residents of Michigan's southern Wayne County.&nbsp;&nbsp;Other requests are limited to employees and physicians affiliated with Henry Ford Wyandotte Hospital.<br><br>Normal turnaround time is 1-2 business days.&nbsp;&nbsp;If your request is urgent, please call (734) 246-7361 for immediate service.<br><br>If you have any problems with this form, please send an email to sladenwebmaster@hfhs.org.<br><br></td>
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				* Indicates required information</span></td>
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						<option value="Administrator/Director" selected>Administrator/Director</option>
						<option value="Extern">Extern</option>
						<option value="Intern/Resident/Fellow">Intern/Resident/Fellow</option>
						<option value="Nurse">Nurse</option>
						<option value="Patient/Consumer">Patient/Consumer</option>
						<option value="Staff Physician">Staff Physician</option>
						<option value="Student">Student</option>
						<option value="Other">Other</option>
					</select>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Phone Number&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_4" class="metadetail" size="35" value="">
					<input type="Hidden" name="eformField_4_required" class="metadetail" value="Phone Number is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Beeper&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">Email Address&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_6" class="metadetail" size="35" value="">
					  
					<input type="Hidden" name="eformField_6_email" class="metadetail" value="Email Address must be a valid email address.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Please Enter Your Information Request:&nbsp;</th>
				<td class="metadetail">
					<textarea name="eformField_7" class="metadetail" cols="40" rows="5"></textarea>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Possible Search Terms:&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">Type(s) of Information Requested:  (You may select more than one option)&nbsp;</th>
				<td class="metadetail">
					<nobr><input type="checkbox" name="eformField_9" id="eformField_9_1" style="{border:0;}" value="Consumer / Patient Health Information">
					<label for="eformField_9_1" class="metadetail">Consumer / Patient Health Information</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_9_1";
						//--></script>
					<nobr><input type="checkbox" name="eformField_9" id="eformField_9_2" style="{border:0;}" value="Allied Health / Nursing Information">
					<label for="eformField_9_2" class="metadetail">Allied Health / Nursing Information</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_9_2";
						//--></script>
					<nobr><input type="checkbox" name="eformField_9" id="eformField_9_3" style="{border:0;}" value="Medical (Professional) Information">
					<label for="eformField_9_3" class="metadetail">Medical (Professional) Information</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_9_3";
						//--></script>
					<nobr><input type="checkbox" name="eformField_9" id="eformField_9_other" style="{border:0;}" value='Other' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_other" class="metadetail">Other</label></nobr>
					<div class="metanew">
						<p class="metanew">
							If Other, please specify:<br>
							<textarea cols="30" rows="3" wrap="soft" name="eformField_9_other_txt" id="eformField_9_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_9_other";
					//--></script>
					<input type="hidden" name="eformField_9_other_txt_required" value='Please provide further details to your answer: Other.' disabled>
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Delivery Options:&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="Pick-up" checked onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_1" class="metadetail">Pick-up</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="Email" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_2" class="metadetail">Email</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="Interoffice Mail" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_3" class="metadetail">Interoffice Mail</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="U.S. Mail (Specify Full Address below)" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_4" class="metadetail">U.S. Mail (Specify Full Address below)</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_5" style="{border:0;}" value="Fax (Specify below)" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_10_5" class="metadetail">Fax (Specify below)</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_10_5";
						//--></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 class="metadetail">&nbsp;</td>
				<td class="metadetail">
					<input type="submit" name="submit" value="Submit" class="metadetail">
				</td>
			</tr>
		</table>
		</form>
	
	
										</td>
                            </tr>
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										<td style="padding:5px 15px 0 15px;"></td>
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      <td height="140" valign="top" style="background-image:url(images/2008/footer.jpg); background-repeat: no-repeat; background-position: top left;"><table width="100%" border="0" cellpadding="0" cellspacing="0">
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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="body.cfm?id=50029"  class="">Billing/Insurances Accepted</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/footermark.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=37460"  class="">About Henry Ford</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/footermark.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=46294"  class="">Press Room</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/footermark.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=45567"  class="">Terms of Use</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/footermark.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=39113"  class="">Privacy Policy</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/footermark.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=48183"  class="">Vendor Information</a></td>		<td class="" valign="middle" align="center" background="" title=""><img src="images/2008/footermark.gif"></td>		<td class="" valign="middle" align="center" background="" title=""><a href="body.cfm?id=40156"  class="">Contact Us</a></td>	</tr></table>
	
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	<br>1-800-HENRYFORD (800-436-7936)&nbsp;&nbsp;&nbsp;&nbsp;Copyright 1997 - 2010</td>
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