Instant Feedback Form

1

Who is filling out this form?* This field is required.

The patient

Someone else, on behalf of the patient (parent/guardian, SDUIH employee, etc.)

2

Which SDUIH location are you wanting to share feedback for?* This field is required.

Pierre Clinic

Sioux Falls Clinic

3

Was your experience positive or do we need to work on something?* This field is required.

PositiveNegative

4

That's great to hear! Please tell us what we are doing right?* This field is required.Please do not put any personal patient-identifying information in this box. If you wish to receive a follow up call or give more detail, please call our Risk Manager at 605-335-2550.

5

Is there anyone we can recognize that went above and beyond to make your experience enjoyable?* This field is required.

6

We're sorry about that! Thank you for taking the time to help us improve. What team was your experience with?* This field is required.

Front desk

Medical Providers

Behavioral Health

Nursing

Cultural Health

Marketplace Navigator

Administration

Transport/CHW

7

Tell us what happened and how we can improve.* This field is required.Please do not put any personal identifying information (names, etc.) in this box. If you wish to file a complaint, please call our Risk Manager at 605-335-2550.

8

Would you like to file a formal complaint?* This field is required.If you wish to file a formal complaint, please reach out to our Risk Manager at 605-335-2550

YES - I will call the Risk ManagerNO THANKS

9

Please verify that you are human* This field is required.

10

If you would like to be contacted further, please leave your name, phone number and address so we can contact you further

Name

Phone Number

Address