To receive a free Healthy Heart Kit with vital information on how to care for your heart, please complete this form.
Name First:
Middle:
Last:
Address:
City:
State:
Zip:
Daytime Phone
Evening Phone
E-mail
Date of Birth:
mo
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
Best Time to call:
(be sure to include phone number(s) above)
a.m.
p.m.
Please send me information on the following:
Cardiac Care
Healthy Heart Kit
Cardiac Risk Factors Guide
Health Guides
Fast Food Nutrition Guide
Cancer Resource Guide
Emergency Guide
Health & Fitness
Fitness & Wellness Class Guide
Women's Health
Women's Heart Care
Life Saving Tests for Women
Breast Self Exam Shower Guide
Children's Health
Parents' Newsletter (HUGS)
Monster Deterrent Kit (Night Light)
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.
Regular Mail
Yes
No
E-Mail
Yes
No
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