Email Address
Male/Female
Age
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 Outstanding Care Award
for
Person, Practice or Hospital Name
Nominee's Phone Number
Nominee's Address
Nominee's Specialty
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Doctor's Name:
Practice or Hospital
Doctor's Email:
Doctor's Phone:
Doctor's Address:
Doctor's Website :
 
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. I give you permission to edit my story to remove inappropriate language and proper names.