Share your Story: Patient Experienceđź’–
✨Thank you for sharing your story and experiences with healthcare services in Santa Clara County ✨This is an opportunity to amplify your voice and highlight the challenges you've faced. The information you provide in this form will support efforts to promote more equitable and accessible care for everyone. We thank you for sharing your perspective and for being a part of this effort. 💝
Full Name
*
First Name
Last Name
Where do you currently live?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
What is the best way to contact you?
*
Email
Text Message
WhatsApp
Phone Call
Other
What language(s) would you prefer we use to communicate?
*
What days work best for you to meet or talk?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What time of day best for you to meet or talk?
*
Morning (7am-12pm)
Midday/Afternoon (12pm-5pm)
Evening (5pm-8pm
Where do you currently receive medical care?
Regional Medical Center
Valley Health Center East Valley
Good Samaritan
Santa Clara Valley Medical Center
Valley Health Center Bascom
Other
After reviewing your responses, a member of the committee will reach out to you to schedule a brief conversation where you can confidently share your experiences and concerns about healthcare. We’re here to listen and learn from you. 💖
Yes
No
Maybe
Submit
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