Works of Heart Submission Form

Your Information

First Name*

Last Name*

Email*

Enter Email Confirm Email

Phone*

Location*

City State / Province / Region

I am a – select from below*

Tell us who you’re nominating (include first and last name) and what makes this person unique.*

Tell us who you’re nominating (include first and last name) and what makes this person unique. *

Tell us where they work and how they’re impacting patients, healthcare community and/or organization.*

Tell us where they work and how they’re impacting patients, healthcare community and/or organization. *

Tell us how this healthcare worker went above and beyond daily duties to improve healthcare.*

Tell us how this healthcare worker went above and beyond daily duties to improve healthcare. *

Tell us how this healthcare worker uses patient empathy to improve healthcare?*

Tell us how this healthcare worker uses patient empathy to improve healthcare? *

Image of the person you are nominating (jpeg, png, gif, and tiff files accepted)

Do you have a photo to submit? Optional.

Photo Upload

2MB max

Link to video about the person you are nominating (YouTube, Vimeo, or any other URL based video link accepted)

Do you have a video submission? Optional.

Video Link

Please provide the URL to the video.

How did you hear about the program?

Please select below. Optional.

Terms and Conditions*

I acknowledge that this contest is subject to the Official Rules. By submitting an entry, I am agreeing to those Official Rules. This is not a sweepstakes; no purchase necessary. Medline employees and their immediate family (spouses, parents, children and siblings) are not eligible to enter or be nominated. *

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Phone

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