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<title>Macomb 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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		<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;
			
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		<table  background="" border="0" cellspacing="0" cellpadding="0">	<tr  background="">		<td width="0%" class=""   valign="top" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Doctor Appointments" id="Nav_Bullet_3_1" name="Nav_Bullet_3_1">&nbsp;</td>		<td class="" valign="top" align="left" background=""><a href="body.cfm?id=46472"  class="">Doctor Appointments</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="top" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td width="0%" class=""   valign="top" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Cancel Appointments" id="Nav_Bullet_3_2" name="Nav_Bullet_3_2">&nbsp;</td>		<td class="" valign="top" align="left" background=""><a href="body.cfm?id=50407"  class="">Cancel Appointments</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="top" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td width="0%" class=""   valign="top" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Mammogram Appointments" id="Nav_Bullet_3_3" name="Nav_Bullet_3_3">&nbsp;</td>		<td class="" valign="top" align="left" background=""><a href="body.cfm?id=52650"  class="">Mammogram Appointments</a></td>	</tr></table>
	
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		<table  background="" border="0" cellspacing="0" cellpadding="0">	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Careers" id="Nav_Bullet_4_1" name="Nav_Bullet_4_1">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="home_careers.cfm?id=49647"  class="">Careers</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Canadian Patient Information" id="Nav_Bullet_4_2" name="Nav_Bullet_4_2">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=46244"  class="">Canadian Patient Information</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Accommodations for Patients and Families" id="Nav_Bullet_4_3" name="Nav_Bullet_4_3">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=46245"  class="">Accommodations for Patients and Families</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Medical Education" id="Nav_Bullet_4_4" name="Nav_Bullet_4_4">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="home_medicaleducation.cfm?id=45425"  class="">Medical Education</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Classes and Events" id="Nav_Bullet_4_5" name="Nav_Bullet_4_5">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=47693"  class="">Classes and Events</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Health Products" id="Nav_Bullet_4_6" name="Nav_Bullet_4_6">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="http://www.henryfordhealthproducts.com/"  target="_blank" class="">Health Products</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Henry Ford at Home" id="Nav_Bullet_4_7" name="Nav_Bullet_4_7">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=37092"  class="">Henry Ford at Home</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Henry Ford OptimEyes" id="Nav_Bullet_4_8" name="Nav_Bullet_4_8">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="homepage_optimeyes.cfm?id=51936"  class="">Henry Ford OptimEyes</a></td>	</tr></table>
	
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valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Health Newsletters" id="Nav_Bullet_5_3" name="Nav_Bullet_5_3">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=40536"  class="">Health Newsletters</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Research" id="Nav_Bullet_5_4" name="Nav_Bullet_5_4">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=45206"  class="">Research</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Nursing at Henry Ford" id="Nav_Bullet_5_5" name="Nav_Bullet_5_5">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=47794"  class="">Nursing at Henry Ford</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Clinical Trials" id="Nav_Bullet_5_6" name="Nav_Bullet_5_6">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=50274"  class="">Clinical Trials</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Information on our Quality" id="Nav_Bullet_5_7" name="Nav_Bullet_5_7">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=46593"  class="">Information on our Quality</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Pricing Information" id="Nav_Bullet_5_8" name="Nav_Bullet_5_8">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=47774"  class="">Pricing Information</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Volunteering" id="Nav_Bullet_5_9" name="Nav_Bullet_5_9">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=47742"  class="">Volunteering</a></td>	</tr>	<tr class=""  background="">		<td class="" colspan="2" valign="middle" align="left" background="" title=""><img src="images/2008/leftnavspacer.gif"></td>	</tr>	<tr  background="">		<td class=""   valign="middle" align="left" background="" title="">&nbsp;<img src="images/2008/left_arrow.gif" border=0 alt="Podcasts from Henry Ford Experts" id="Nav_Bullet_5_10" name="Nav_Bullet_5_10">&nbsp;</td>		<td class="" valign="middle" align="left" background=""><a href="body.cfm?id=48646"  class="">Podcasts from Henry Ford Experts</a></td>	</tr></table>
	
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						<span class="pageName">Macomb Library Information Request Form</span>
						
						
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			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Email Address&nbsp;<span class="required">*</span>&nbsp;</th>
				<td class="metadetail">
					<input type="Text" name="eformField_5" class="metadetail" size="35" value="">
					  
					<input type="Hidden" name="eformField_5_email" class="metadetail" value="Email Address must be a valid email address.">
					<input type="Hidden" name="eformField_5_required" class="metadetail" value="Email Address is required.">
				</td>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail">Please Enter Your Information Request:&nbsp;</th>
				<td class="metadetail">
					<textarea name="eformField_6" 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_7" 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_8" id="eformField_8_1" style="{border:0;}" value="Consumer / Patient Health Information">
					<label for="eformField_8_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_8_1";
						//--></script>
					<nobr><input type="checkbox" name="eformField_8" id="eformField_8_2" style="{border:0;}" value="Allied Health / Nursing Information">
					<label for="eformField_8_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_8_2";
						//--></script>
					<nobr><input type="checkbox" name="eformField_8" id="eformField_8_3" style="{border:0;}" value="Medical (Professional) Information">
					<label for="eformField_8_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_8_3";
						//--></script>
					<nobr><input type="checkbox" name="eformField_8" id="eformField_8_other" style="{border:0;}" value='Other' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_8_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_8_other_txt" id="eformField_8_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_8_other";
					//--></script>
					<input type="hidden" name="eformField_8_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;</th>
				<td class="metadetail">
					<nobr><input type="radio" name="eformField_9" id="eformField_9_1" style="{border:0;}" value="Pick-Up" checked onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_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_9_1";
						//--></script>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_2" style="{border:0;}" value="Email" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_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_9_2";
						//--></script>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_3" style="{border:0;}" value="Interoffice Mail" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_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_9_3";
						//--></script>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_4" style="{border:0;}" value="Fax (specify number)" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_4" class="metadetail">Fax (specify number)</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_9_4";
						//--></script>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_5" style="{border:0;}" value="U.S. Mail (specify address" onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_5" class="metadetail">U.S. Mail (specify address</label></nobr><br>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_9_5";
						//--></script>
					<nobr><input type="radio" 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><br>
					<nobr><input type="radio" name="eformField_9" id="eformField_9_none" style="{border:0;}" value='None' onClick="return smm_eforms_toggle_other(this);">
					<label for="eformField_9_none" class="metadetail">None</label></nobr>
						<script language="JavaScript" type="text/javascript"><!--
						smm_eforms_toggle_other_to_init[smm_eforms_toggle_other_to_init.length] = "eformField_9_none";
						//--></script>
					<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" colspan="2" style="{text-align:center;}">Normal turnaround time is 1-2 business days.  &nbsp;</th>
			</tr>
			<tr class="metadetail">
				<th valign="top" class="metadetail" colspan="2" style="{text-align:center;}">If your request is urgent, please call (586) 263-2485 for immediate service.&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 - 2009</td>
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