Provider of Excellence Award
Nominate your provider today in honor of Dr. Richard Weiland.
1. Please provide your first and last name:
First Name
Last Name
2. What is your phone number?
Please enter a valid phone number.
3. What is your email?
example@example.com
4. Please contact me if my provider nominee is chosen.
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Yes
No
5. Provider Name
6. Please share the story of why your provider nominee should be honored for the compassion and care they provide their patients every day. Be sure to include how your nominee embodies and values community impact, leadership, integrity, and patient-centered care.
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Authorization (Please check all that apply)
*
I authorize Tri-State Marketing & Communications to contact me regarding my Provider of the Year Award nomination.
I authorize Tri-State Marketing & Communications to share my Provider of the Year Award nomination on Tri-State Memorial Hospital's social media page.
I authorize Tri-State Marketing & Communications to include my name when they share my Provider of the Year Award testimonial on Tri-State Memorial Hospital's social media page.
I would like to be added to Tri-State Memorial Hospital's email list to receive messages regarding hospital changes, updates, service lines, provider information, or general marketing communications.
None of the above.
Please sign below to authorize all of the above checked boxes.
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