How Are We Doing?

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Feedback Type
- Compliment
- Complaint
Name*
Patient First Name Patient Last Name
Patient Date of Birth
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Patient Phone Number
Patient Phone Type (Select One)
Patient Email Address
Are you the patient or submitting on behalf of the patient?*
- I am the patient.
- I am submitting on behalf of the patient.
Submitter Name
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Submitter Phone Number
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How Do You Wish To Be Contacted? (Select One)*
Event Date
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Provider
Description of Feedback
When you “submit” your feedback, your comments will be forwarded to the appropriate management staff, who will be contacting you in the near future. Thank you for taking the time to tell us about your experience at Florida Medical Clinic Orlando Health.
Thank you for submitting your feedback. Your feedback may be used for training and educational purposes by Florida Medical Clinic Orlando Health. Your positive feedback may also be shared on other Florida Medical Clinic Orlando Health social media accounts and public domains (e.g., YouTube, Facebook, Instagram).
If you do not want your feedback shared please check the box
Feedback Consent
Thank you for submitting your feedback. Your feedback may be used for training and educational purposes by Florida Medical Clinic Orlando Health. Your positive feedback may also be shared on other Florida Medical Clinic Orlando Health social media accounts and public domains (e.g., YouTube, Facebook, Instagram).
I do not wish for my feedback to be shared.
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