Student Feedback/Request Form

Student Health Services needs patient feedback in order to maintain and improve services. It is our goal to continually monitor and evaluate services to ensure that students’ needs are being addressed. Please feel free to fill out our online form to leave a comment or to request an action regarding your charges, service, or visit. We look forward to hearing from you!

  • Date Format: MM slash DD slash YYYY
  • :
  • Please use the space below to describe the circumstances surrounding your visit in question. Please make note of any SHS staff that you interacted with during your visit and be as specific as possible as to the events that occurred.
  • Please list any actions you feel should be taken as a result of your visit and events above.
  • This field is for validation purposes and should be left unchanged.

To submit a hard copy of this form, download the form and deliver completed form to the Patient Services office in the A.P. Beutel Health Center.

Form available here: Student Feedback/Request Form