Courtesy Staff Facility Request

Please fill out the following information and a Gundersen Health System representative will contact you.

New Facility Information

Contact *
Organization *
Physical Address: *
Contact Phone:

*

( Format: 608-782-7300 )
Email Address: *
Is your organization considered an assisted living facility?

Yes No *
Does your facility admit or provide other post-discharge services?

Yes No *
Do you want to receive Admission Referrals via GHS Link?

Yes No I'd like more information
Comments:

Fields marked * are required.