Contact Us

Intro blurb needed to introduce this form.

*	required items
>>	*Last Name:

>>	*First Name:

>>	*Phone Number:

>>	E-mail:

>>	*Relationship to hospital: (choose all that apply)
	Current patient Former patient Family member of patient Current employee Former employee Potential or future patient
>>	*If a current or former patient, please give dates of your stay with us:

>>	*If a family member of patient, please give name and dates of family member’s stay:

>>	*Comments:

[programming note: submitted form should redirect to /about/thank-you.htm; set form to e-mail to hcarroll@trhta.net (this will change); note scripting required to make the dates of stay questions only be required if appropriate box is checked; AUTO REPLY e-mail text should be as follows:

Thank you for contacting us. Your input is important. Our desire is to make your health care experience as positive as possible. We will contact with you within five business days.

Visit www.PCCHtx.com for more information.

Sincerely,
PCCH Staff

]

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