Licking Memorial Health Systems - Patient Satisfaction Form

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Patient Satisfaction Feedback Form

We welcome any feedback you would like to give us regarding your experience in any of our facilities. Complete customer satisfaction is of utmost importance to us. If you would like to share any comments regarding your visit with us, please complete the following feedback form. Any type of feedback received will be followed up through our customer care personnel, as it will greatly contribute toward assisting us in improving the quality of our services and care.

Visitor Information:

Full name:

Address:

City:

State:

Zip code:

Phone number:

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E-Mail:

Date of visit:

Location:

Comments/Suggestions:

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Please note: Messages submitted through this form are reviewed during regular business hours and are not continuously monitored. While many inquiries may receive a response sooner, please allow up to two business days for a reply. This form should not be used for urgent medical concerns or emergencies. If you need immediate assistance, please contact us by phone at (220) 564-4000 or call 911 in an emergency. Additional direct dial numbers can be found on our Phone Directory page.