You can always press Enter⏎ to continue
Patient Feedback
Hi there! Please let us know about your experience and how we may improve.
5
Questions
START
HIPAA
Compliance
1
Name
You may leave your name blank if you wish to remain anonymous. However, we encourage you to give us your information so that we may have our Quality Improvement team investigate the issue and provide additional training to staff as needed.
First Name
Last Name
Previous
Next
Submit
Press
Enter
2
Phone Number
Please enter a valid phone number.
Previous
Next
Submit
Press
Enter
3
Which location is this feedback regarding?
*
This field is required.
La Pine - Huntington Rd
La Pine - Huntington Rd - WALK-IN
La Pine School Based Health Center
Gilchrist School Based Health Center
Other - Virtual Visit
Other - Telephone Call
Previous
Next
Submit
Press
Enter
4
Who is this feedback regarding?
Rebecca Brewer
Janice Cody
Dr. Joan Friderici
Mariam Hameed
Tyson Langeliers
Dr. Adaobi Okonkwo
Dr. Divya Sharma
Sarah Sperry
Sally Grosse, Mental Health
Megan Lewis, Mental Health
Joeth Ryan, Mental Health
Jay Flesch, Clinical Pharmacist
Other - Adam Burr
Other - Megan Lindley
Other - Outreach
Other - Medical Assistant
Other - Nurse
Other - Reception
Other
Previous
Next
Submit
Press
Enter
5
Please describe your experience and let us know how we may improve.
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
5
See All
Go Back
Submit