Bon Secours Patient Experience

We’re here to serve you, and we consider you a partner in your care. When you are well-informed, participate in treatment decisions and communicate openly with your doctor and other health professionals, you make your care as effective as possible. This facility encourages respect for the personal preferences and values of each individual.

Any information you provide to us through this form will be treated confidentially but may be used and disclosed as described in our Notice of Privacy Practices. Permitted uses include internal performance improvement activities.

First Name

Last Name

Phone Number

City

State

Are you the Bon Secours patient this is regarding?

YesNo

Date of Birth (mm-dd-yyyy)

Patient's First Name

Patient's Last Name

Patient's Date of Birth (mm-dd-yyyy)

Bon Secours Region

Greenville Location

If Urgent Care or Physician's Office, please specify provider's name and location:

Hampton Roads Location

If Urgent Care or Physician's Office, please specify provider's name and location:

Richmond Location

If Urgent Care or Physician's Office, please specify provider's name and location:

How was your experience with us?

PositiveNeutralNegative

Please describe your experience, including location and date of service:

Would you like for a patient relations or billing representative to contact you?

Yes, I'd like to speak with a patient relations representative.Yes, I'd like to speak with a billing representative.No, I do not wish to speak with anyone about my experience.

Phone Number - If yes, please give us the best phone number to reach you if different from above:

Please attach any photos/screenshots related to your experience here:

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