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* 1. Submitter's Name

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* 2. Tell us about you.

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* 3. Please share your email address.

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* 4. Please share your phone number.

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* 5. PETALS Nominee's Name

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* 6. Nominee's Unit or Department

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* 7. Please describe a specific situation or story that demonstrates how this nominee made a meaningful difference in your care.

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* 8. If the nominee is awarded the PETALS Award for Professional Extraordinaire would you like to be a part of the celebration.

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* 9. By selecting Yes and submitting this online form, you agree to collecting and storing the information you submit, including your personal contact information, in accordance with the Augusta Health Privacy and applicable law. Augusta Health where your nominee works may contact you with questions about your submission.

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