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Enter your story
Email Address
Male/Female
Age
In this story I was
Patient
Family Member of a Patient
Physician
Dentist
Administrator/Manager - Medical
Administrator/Manager - Dental
Credentialed Medical Staff
Non-Credentialed Medical Staff
Credentialed Dental Staff
Non-Credentialed Dental Staff
I would describe the doctor(s) in my story as
(select as many as fit):
Friendly
Insulting
Rude
Focused
Helpful
Scattered
Rushed
Good Listener
Warm
Not interested in my concerns
Cold
Good Communicator
Encouraging
Poor Communicator
I would describe the staff member(s) in my story as
(select as many as fit):
Friendly
Insulting
Rude
Focused
Helpful
Scattered
Rushed
Good Listener
Warm
Not interested in my concerns
Cold
Good Communicator
Encouraging
Poor Communicator
I nominate
to receive
the 2010 Professional Impact Five-Star Care Award
for
Medical
Dental
Person, Practice or Hospital Name
Nominee's Phone Number
Nominee's Address
Nominee's Specialty
If you would like us to send your story anonymously to your doctor, please check here and complete the following information:
Doctor's Name:
Practice or Hospital
Doctor's Email:
Doctor's Phone:
Doctor's Address:
Doctor's Website :
How did you hear about MyDoctorStory.com?
Radio
Television
Print
My Doctor
Other
Your First Name
By clicking "Submit" I give you full permission to use my story in any way that you see fit to help make a difference in healthcare. I understand that my privacy will be maintained. I waive all rights to this story and will not seek to receive compensation. I understand that should my story be chosen for publication, I will receive notification and will be asked to sign a release form before my story can be used.