Patient Testimonial Survey

Thank you for taking this survey! We are interested in your honest opinions so that we can continue to provide quality care.

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* 1. Personal Information

Name *

City *

State

Email Address *

Phone Number

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* 2. Overall, how satisfied were you with the experience at AVHS?

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* 3. How did you hear about us?

Social Media

Google

Radio

Family\Friend

Other (please specify)

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* 4. Would you recommend us to your family and friends?

Yes

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* 5. We would love to hear about your experience. Please share with us about your experience.

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* 6. Is there an AVHS employee or department you would like us to highlight? If yes, please explain why.

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* 7. May we share your testimonial on our AVHS social media platforms?

Yes

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* 8. Would you like to be identified or remain anonymous?

Name

Anonymous

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* 9. Consent

I agree that by checking the box, I authorize giving my testimonial as a patient treated by Artesian Valley Health System. I understand that submitting my testimonial does not guarantee my testimony's use. I understand that by submitting my testimony, I give Artesian Valley Health System the right to use my testimonial for reproduction in any medium, including but not limited to: website, video, broadcast, print, and electronic means for purposes of advertising, trade, display, presentation or editorial use. The undersigned releases Artesian Valley Health System from all claims of libel, slander, invasion of privacy, infringement of copyright, right of publicity, or any other claim.