*indicates required field

*Request Date:

*Date Needed:

  Needed for URGENT PATIENT CARE:

 Yes   No

*First Name:

*Last Name:

*GSH Employee:

 Yes   No

  GSH Staff/Student:

 Yes   No

*Medical Staff:

 Yes   No

*Email address:

*Phone Number:

Extension:

  Beeper Number:

  Fax Number:

*Main Search Topic:

*Subtopics and Qualifiers:

  How far back:

1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years 11 Years 12 Years 13 Years 14 Years 15 Years 16 Years 17 Years 18 Years 19 Years 20 Years

  English Only:

 Yes   No

  Foreign Language:

 Yes   No

  Age Group:

 eg. Infant, child, adolescent, adult, aged

*Delivery:

Hospital Mailbox Pickup at Library Fax Email Mail to Home Mail to Office

  Mailing Address: required if mail to home/office is selected above

Address:

City:

State:

Zip:

Please note: Staff students must pick up items at library.  It is your
responsibility to call the library to see if they have arrived.