Patient Testimonial

Patient Testimonial

If you had amazing care at Good Samaritan and want to share your story or recognize any of our caregivers who made your experience so great, we would love for you to fill out this form!
Please note this testimonial form is for Good Samaritan Hospital in Vincennes, Indiana.
How would you rate your care at Good Samaritan in Vincennes, Indiana?*
What service or procedure did you have at Good Samaritan?*
If you were an inpatient, which unit were you on?
Who was your physician(s)?*
What would you like to share about your experience at Good Samaritan? What made it unique? We would love to hear it all, from the moment your experience started all the way to the end! *
Are there any staff members who went above and beyond who deserve recognition? Is so, we would love for you to share their names and the details of how they impressed you!
Why did you choose to receive your care at Good Samaritan?
What would you say to your friends about Good Samaritan if they are asking for recommendations for their health care needs?
Is there anything that we could be doing better?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
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Phone Number
Please enter a valid phone number.
Can our Marketing Department contact you about your story to possibly use for hospital promotion?

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If you would like to go ahead and give Good Samaritan permission to share your story on our website and in other hospital publications, please click here to read and sign our HIPAA release form.
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