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Name Of Nominee:

Daytime Phone:

Your Name:

Daytime Phone:

Your Address:

Is the nominee a   (please check):

q Cardiologist

    q Internist

 q Family Practice Physician

q Emergency Room Physician

q Cardiothoracic Surgeon

 q Other

What is your relationship to the nominee?                                                                                              

Briefly describe your condition/illness and the outcome of your treatment:

Please describe the one aspect of the care provided that you consider exemplary:

What do you consider to be the most outstanding quality of your cardiac care provider?

Were there any obstacles that the nominee had to overcome?         q Yes          q No

If so, what were they and how were those obstacles overcome?

If you are a health care professional, what did you observe about the physician’s care that prompted you to submit the application?

If you are a patient, what would you say to your nominee if you could speak from your heart about the care that was extended to you during your illness?