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FREE FIRST AID KIT
for telling us a little bit about yourself.
To get your FREE FIRST AID KIT, along with information about Samaritan Health Services, just complete the information below.
Gift Code: 
Name First:  Middle:  Last: 
Address: 
City:  State:  Zip: 

Phone: 
E-mail: 
Birthdate (optional): mo
day
year
Gender Male
Female
Number of children in household: Age 5 or under  6-11  12-17 
Do you have a health insurance plan? Yes
No
I would like Samaritan's Physician Referral Line to give me information on visiting a:
Family Practitioner OB/GYN Pediatrician Internist Other  
Best time to contact, Monday through Friday between 8 a.m. and 5 p.m.:
(Be sure to include contact information above)
 

Please send me information on the following:

Healthy Kids Kit
Women's Health Kit
Healthy Heart Kit
Nutrition and Wellness Kit
Would you also like to receive a free three-day pass to any SamFit gym located in Albany, Corvallis or Lebanon?

Please let us know if you would like to receive future health care communications (e.g. newsletters, preventive health or event information) in the following formats. Our goal is to provide the information you desire in the format you prefer.
Regular Mail Yes
No
Email Yes
No
Your privacy is important to us. The information gathered will only be used by Samaritan Health Services and will not be shared in any way with a third party.
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