Share YOUR story with us!
Had a great experience at Terrebonne General Health System? Would you recommend Terrebonne General to your friends and family? If you would like to share your experience with us, please give us as many details as possible about your overall experience and story.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Age Acknowledgement
*
I certify that I am 18 years of age or order
Terrebonne General Health System Authorization
*
By checking this box, I authorize Terrebonne General Health System to utilize my story and relevant portions of my medical record.
Use of Story Authorization
*
I authorize the Marketing & Planning Department to contact me regarding using my patient story. *Disclaimer: Not all stories will be shared publicly.
File Upload
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If you upload your story in the field above, you DON'T need to type/paste it in the field below.
Cancel
of
Your Story
*
Please list any treating physician(s), nurse(s), or other staff member(s) you would like to acknowledge here.
Please list services or departments visited.
ex: Lab, Women's Center, Med/Surg, etc.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Contact information for person submitting form (if other than patient)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Authorization
I am the parent or authorized guardian of the aforementioned patient.
Continue
Continue
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