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The Teddy Tour

Thank you for your interest in Potomac Hospital's tours for children who are having surgery. Please complete and return this form electronically to arrange a tour for your child or for more information. A surgical team member will contact you by telephone or e-mail to confirm tour date and time.

 

Parent/Guardian's First Name:




Parent/Guardian's Last Name:


 
Name of Child Having Surgery at Potomac Hospital:
Child's Age:
Date of Surgery:
 
Surgeon's Name:
 
* Preferred Day for Tour * Preferred Time for Tour:
 
* A surgical team member will contact you by telephone or e-mail to
confirm your tour day and time. We will make every effort to accommodate
your preferred day and time.
E-Mail Address:
Mailing Address:
City:

State:     

Zip:

Home Phone:
Work Phone:
Comments/Questions:

 

 

 

This page was last updated on March 15, 2007