Schedule a Radiology Appointment

First & Last Name

Home Address

City

State

Zip

Date of Birth

Email

Primary Phone

Best Time(s)/Day(s) to Call You

Primary Language

Additional Language(s):

Activities/Hobbies (tell us about yourself!)

Occupation

Have you used Bayou Bend Health System services in the past year (12 months)? Check all that apply:

Other:

Has a close family member used Bayou Bend Health System services in the past year (12 months)? Check all that apply:

Other:

Are you able to commit to attending quarterly meetings at the hospital from 3:30 - 5:00 PM?

Yes

No

Please tell us in a few sentences why you would like to be part of this committee.