Penn Highlands Healthcare Physician Video Schedule Request Practice Manager Name(Required) First Last Best Way of Contact(Required)Practice Name(Required)Number of Doctors in Practice(Required)12345General Geographic Area Served(Required)Mon ValleyConnellsvilleDetails on FilmingThe True Fit Marketing Video Team will will come out to the Penn Highlands Mon Valley and Connellsville area hospitals and Doctor's offices on the following days to create your "Meet the Physician" videos for each of your Physicians! We only need about 20 - 25 minutes of the Physician's time, and we will capture about 15 - 20 minutes of video to create a 2 minute video about them. Below, please choose two date and time options for your Physician. Please note, the Practice Manager for each practice will receive an email, about a week out of the scheduled date/time, with specific details regarding date/time slot (about 20-25 minutes)/location for each Physician.) Please choose a #1 and #2 preferred day/time.First Doctor Name (Please list full name, including Title and Expertise)(Required)Doctor's Filming Location (*Doctor's Office Address*)(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code #1 Preferred Day/Time (Choose One)(Required) Thursday, November 2, 10am - 12pm #2 Preferred Day/Time (Choose One)(Required) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm Second Doctor Name (Please list full name, including Title and Expertise)Doctor's Filming Location (*Doctor's Office Address*) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code #1 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm #2 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm Third Doctor Name (Please list full name, including Title and Expertise)Doctor's Filming Location (*Doctor's Office Address*) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code #1 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm #2 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm Fourth Doctor Name (Please list full name, including Title and Expertise)Doctor's Filming Location (*Doctor's Office Address*) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code #1 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm #2 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm Fifth Doctor Name (Please list full name, including Title and Expertise)Doctor's Filming Location (*Doctor's Office Address*) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code #1 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm #2 Preferred Day/Time (Choose One) Monday, September 25, 10am - 12pm Wednesday, October 11, 1pm - 3pm Thursday, October 12, 10am - 12pm Wednesday, October 18, 1pm - 3pm Thursday, October 19, 10am - 12pm Thursday, November 2, 10am - 12pm Please include any notes or questions here:If any scheduling concerns are met along the way, please let us know as soon as you are able by emailing our Office Manager at [email protected]. We will work with you to reschedule, as we are very appreciative of each Physician's time. Thank you and we look forward to working with you and your Physicians. Questions? Please email our Office Manager at [email protected].