Information Request Form


We would be pleased to send you additional information by mail. Simply fill out this form and information will be sent to you promptly.

PLEASE CHECK ALL THAT APPLY:

Hospital Programs and Services
Calendar of Events (you can also click here to access it)
Associated Physicians Index (you can also click here to access it)
Health Related Topics (please specify which topic)
General Information on Putnam Hospital Center

Have you ever used any of the following services offered at PHC?

Inpatient
Outpatient
Medical Staff
Community Education Programs
Other
No, I have never used PHC

Please provide us with the following contact information:

Name
Title
Organization
Street address
Address (cont.)
City
State/Province
Zip/Postal code
Country
Work Phone
Home Phone
FAX
E-mail