Type of Feedback
*
Share a compliment/feedback
Share a concern
First Name
*
Write "Anonymous" if you do not want to be identified.
Last Name
*
Write "Anonymous" if you do not want to be identified.
Patient Representative: First and Last Name
If the patient is not submitting this form, please write your first and last name.
Mayo Clinic Number
If anonymous enter "0"
Date of Birth
*
Phone Number
*
Please enter a phone number where you can be reached. If anonymous, enter 000-000-0000.
Email Address
Please enter your email address.
Date of Care
*
Department or Specialty
Please write the specific department or specialty clinic where you were seen.
Feedback
*
Please write a short description of the feedback you would like to provide.
Is the Patient Requesting a call back?
*
No
Yes- 8 AM to 5 PM
Yes- 8 AM to12 PM
Yes- 12 PM to 5 PM