Share your Story: Patient Experience💖

Share your Story: Patient Experience💖

✨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 NameLast Name
Where do you currently live?*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
What is the best way to contact you? *

EmailText MessageWhatsAppPhone CallOther
What language(s) would you prefer we use to communicate?*
What days work best for you to meet or talk?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
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?*
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. 💖

YesNoMaybe
Should be Empty: