Mercy Health 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
Email
Phone Number
City
State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
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Ohio
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Pennsylvania
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South Carolina
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Texas
Utah
Vermont
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Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Are you the Mercy Health patient this is regarding?
Yes
No
Date of Birth (mm-dd-yyyy)
Patient's First Name
Patient's Last Name
Patient's Date of Birth (mm-dd-yyyy)
Mercy Health Region
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Cincinnati, OH
Lima, OH
Lorain, OH
Springfield, OH
Toledo, OH
Youngstown, OH
Irvine, KY
Paducah, KY
Cincinnati Location
Please select...
Anderson Hospital
Clermont Hospital
Eastgate Medical Center
Fairfield Hospital
Harrison Medical Center
Kings Mills Hospital
Liberty Falls Medical Center
Mt. Orab Medical Center
Queen City Medical Center
Rookwood Medical Center
The Jewish Hospital
West Hospital
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
Lima Location
Please select...
St. Rita's Medical Center
Putnam County Emergency Services
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
Lorain Location
Please select...
Allen Hospital
Lorain Hospital
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
Springfield Location
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Urbana Hospital
Springfield Regional Medical Center
Dayton Springfield Emergency Center
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
Toledo Location
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Defiance Hospital
Perrysburg Hospital
St. Anne Hospital
St. Charles Hospital
St. Vincent Medical Center
Tiffin Hospital
Willard Hospital
Sylvania Medical Center ED
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
Youngstown Location
Please select...
St. Elizabeth Boardman Hospital
St. Elizabeth Youngstown Hospital
St. Joseph Warren Hospital
Austintown Medical Center
Warren Minor Emergency Services
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
Kentucky Location
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Marcum & Wallace Hospital
Lourdes Hospital
Mercy Health Urgent Care
Primary Care/Physician's Office
If Urgent Care or Physician's Office, please specify provider's name and location:
How was your experience with us?
Positive
Neutral
Negative
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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