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Medical Staff Feedback Form

IMPORTANT MESSAGE: The information on this form will be sent in an unsecure transmission and could possibly be monitored or intercepted by unauthorized third parties. CHRISTUS Santa Rosa is not responsible for any unauthorized monitoring or interception of unsecure transmissions. The following requested demographic information is optional. It is included only because we are very interested in your comments and would like to respond to you as soon as possible. However, if you would like to go directly to the "Comments" field, please do so. Thank you for taking the time and caring enough about CHRISTUS Santa Rosa to give us your feedback.

First and Last name:

MD DO DDS DPM Other

Specialty:

Contact Information

Phone number:

E-mail address:

Questions

1. Do you currently have privileges at any one of the CHRISTUS Santa Rosa facilities?

Yes No

If yes, where?
CSR Hospital City Center
Medical Center
Rehabilitation
CSR Children's Hospital

If no, would you like to apply for privileges?

Yes No

If yes, please complete our online request form and fax to (210) 704-3642 or e-mail to matthew.stedman@christushealth.org.

2. Are you currently recruiting for a partner or expanding your practice?

Yes No

Comments

Please provide your comments or suggestions so that we can continue to improve our service to you and your patients.

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