Baytown: Answer Our Quick Survey for a Chance to Win a Free $100 Gift Card!

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* 1. If there was a Free App that would make your life easier before or after your visit to the ER, would you use it?

Yes

No

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* 2. Your App Wishlist! What would that mobile application be able to do? For example, "It would help me": Check into the ER? Make payments on your ER bill? Getting back certain test results? Please list all that you would like the App to do.

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* 3. What is your contact information? We would use this to reach out to you if you win.

Name *

City/Town

Email Address *

Phone Number