The Future of Beth Israel Hospital: An Online Community Information-Sharing and Discussion Forum

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Request for Participation Form

Have you been a patient at Beth Israel Hospital during the past decade, or do you want or plan to seek services there in the future?
*

Have you been a family member or caregiver for a patient who received services at either Beth Israel Hospital over the past decade?
*

Are you a resident of Lower Manhattan or at some point(s) over the past decade? *

If so, what neighborhood(s) do you or did you live in?

Name *

Email address *

Phone number *

Good times to call you *

Your race or ethnicity

Your age group

Your gender

Questions or comments?

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