Share Your MPH Story

Share Your Story

Your experience matters. By sharing your healthcare story, you help Middle Park Health improve care, recognize exceptional staff and providers, and inspire others in our mountain communities. Stories may also be shared by Middle Park Medical Foundation to highlight the impact of local philanthropy.You may skip any question you prefer not to answer.
SECTION 1: CONTACT INFORMATION
Full Name

First NameLast Name
Preferred Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date

MonthDayYear
Date
May we contact you if we have questions about your story?
SECTION 2: YOUR MIDDLE PARK HEALTH EXPERIENCE
Which Middle Park Health location(s) or service(s) were part of your experience?

Other
If "Other," Please describe
SECTION 3: YOUR STORY
What brought you to Middle Park Health?
What stood out to you about the care you received?
How did this experience impact you or your family?
Is there a specific moment or interaction you’ll always remember?
How would you describe Middle Park Health to a friend or neighbor?
Why do you believe local healthcare is important to our community?
Rate your experience at MPH.
SECTION 4: RECOGNIZING STAFF & PROVIDERS

Your recognition may be shared internally or used by Middle Park Health Foundation to celebrate staff excellence.
Would you like to recognize a Middle Park Health staff member, provider, or department? (Names are appreciated but not required.)
What made their care or support especially meaningful to you?
SECTION 5: STORY SHARING & CONSENT
May Middle Park Health and Middle Park Health Foundation share your story?
How may your story be shared?
Are you open to being photographed or recorded?
SECTION 6: SUPPORTING MIDDLE PARK MEDICAL FOUNDATION 💙
Many patients ask how they can give back. Would you like to learn more about supporting Middle Park Health through the Foundation?
Middle Park Health Foundation is a 501(c)(3) nonprofit that supports patient care, staff, and health programs across our communities.
Is there anything else you’d like to share?
HIPAA & MEDIA CONSENT LANGUAGE

Authorization & Consent
I authorize Middle Park Health and Middle Park Health Foundation to use my written story, quotations, photographs, video, or audio recordings for purposes including, but not limited to: patient education, staff recognition, marketing, fundraising, community outreach, and Foundation publications.

I understand:

My participation is voluntary
I may choose to remain anonymous
My decision will not affect my care or benefits
My story will not include protected health information beyond what I voluntarily provide
Consent Checkbox
Signature
Should be Empty:

Share Your Story

SECTION 1: CONTACT INFORMATION

SECTION 2: YOUR MIDDLE PARK HEALTH EXPERIENCE

SECTION 3: YOUR STORY

SECTION 4: RECOGNIZING STAFF & PROVIDERS

SECTION 5: STORY SHARING & CONSENT

SECTION 6: SUPPORTING MIDDLE PARK MEDICAL FOUNDATION 💙

HIPAA & MEDIA CONSENT LANGUAGE