Patient Feedback Form

 

Please Fill Out The Form Below

 

    Feedback Type

    ComplimentSuggestionComplaint

     

    Contact Information

    The Quality department may contact you regarding your feedback and the below information is greatly appreciated.
    Name:
    Address:
    Date of Birth:
    Chart # (if known)
    Contact Number:

     

    Comments (required):

     

    Would you like to receive a call in relation to your comments?
    YesNo

     

     

     

    Disclaimer: Samuel Simmonds Memorial Hospital provides patient-centered care and encourages reporting of safety issues, complaints, comments, suggestions, and compliments. Reporting helps SSMH identify, review and resolve problems. SSMH will not retaliate or refuse service to those who report their concerns. We thank you for your time and input into the matter.

    Arctic Slope Native Association

    PO Box 1232

    7000 Uula Street

    Utqiaġvik, Alaska 99723

    Main Line: 907 852 4611

    Toll Free: 1 800 478 3033

    Samuel Simmonds Memorial Hospital

    PO Box 29

    7000 Uula Street

    Utqiaġvik, Alaska 99723

    Quality Department: 907 852 9155

    Main Line: 907 852 4611

    CONTACT

    ABOUT ASNA

    Directory

    Previous page
    Processing...
    Thank you! Your subscription has been confirmed. You'll hear from us soon.
    ErrorHere