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How are we doing?

We appreciate your comments about the medical services and educational programs provided by CRMC. Please use this form to tell us how we are doing. If you are a patient and would like a patient satisfaction survey sent to your home click here.
Your role in service or program:
   
Service Provided:
           Other:
   
Date of service/program: / / (month/day/year)
   
Did the service/program meet your expectations? Yes No
Comments:
   
Was the staff professional and courteous? Yes No
Comments:
   
Would you recommend this service or program? Yes No
Comments:
   
How can this service/program be improved?
   
What other services/programs would you like to have offered?
   
Is there an employee or staff member deserving of special recognition?
   
To receive information about programs and services at CRMC, please complete the brief registration form below. The information you provide will be carefully protected according to our privacy policy.
 
      Please add me to your e-mail news list for health programs and services.
      Please add me to your mailing list for health programs and services.
   
I am interested in receiving information on the following:
Asthma/Respiratory Therapy
Cancer/Oncology
Cardiac/Heart
Clinic Services
Corporate Health
Diabetes
Educational Program
Emergency
Fitness
Health Screening
Home Health
ICU
Men's Health
Mental Health/Counseling
Obstetric/Maternal Health
Pediatric/Child Health
Rehabilitation/Therapy Services
Senior's Health
Skilled Nursing Facility
Surgery
Women's Health
Wound Care
Other (Fill In Below)
    
   
*Required fields  
   
First Name:*
Last Name:*
Street Address:
City:
State:
Zip:
Email Address:
Phone Number:
Age
Gender: Male Female
   
Please have a representative contact me to discuss my comments about CRMC's programs or services. (The above information must be complete.)