Community Feedback Form

Thank you for taking the time to offer feedback regarding your experience with Adventist Health. We appreciate your providing this information so that we can consider it as we strive to become the best place to receive care.
Have you received service at Adventist Health? *

Yes No
If yes, please list the approximate date of service:

Month Day Year
If yes, please select the location of service:

Adventist Health Hanford Adventist Health Reedley Adventist Health Selma Adventist Health Tulare Adventist Health Medical Office Physicians Network Medical Office Kerr Outpatient Center
If you received care at a medical office, please specify which city.
Comments
Additional information that is helpful to us: (optional)
1. Have you used the services of another hospital in the last year?

Yes No
If so, would you share the facility name?
2. What health care services would you like to see added at Adventist Health?
3. Do you travel out of town for physician services?

Yes No
If so, what type of service?
Name

First Last
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number

Area Code Phone Number
Should be Empty:

Additional information that is helpful to us: (optional)