Patient Feedback

Feedback Form

Use the form below to share your thoughts!
Your healthcare experience is very important to us. Please share your feedback so we can improve patient care and also celebrate employees who provided great service. We appreciate your time!
Name*

First NameLast Name
Contact Number:*
E-mail
example@example.com
Is this feedback about a patient visit?*

YesNo
Which clinic did you visit?*
Which service area is this feedback for?*
Other, please specify:
Is this feedback about a positive or negative experience?*
Is this feedback about customer service or healthcare you were provided during your visit?*
Please tell us about your patient visit.
Please tell us about your experience.*
Is there anyone you would like to recognize for providing excellent service? Please share their name with us above so we can celebrate them!
Optional: Who was your provider?
Thank you for your time sharing your feedback with us!
Submit this form by clicking the "Submit" button below.

Please note: This form is for feedback only and is not to be used for requesting or canceling a new or existing appointment. To do this, please call (425) 789-3789.
If you have feedback for CHC, unrelated to a patient visit, please call Administration at 425-789-3700 or send a note to us at:

Community Health Center of Snohomish County
Administration
8609 Evergreen Way
Everett, WA 98208
For additional assistance, call:
425-789-3789.
Should be Empty:

Feedback Form