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Student Feedback/Request
If you are submitting feedback regarding a visit and/or experience at SHS, please check the box and complete the following fields so we can best serve you.
If you are submitting feedback regarding a visit and/or experience at SHS, please check the box and complete the following fields so we can best serve you.
- I need to submit feedback regarding my visit/experience at SHS.
I would like to submit a:*
Please select all that apply.
- Compliment
- Complaint
- Suggestion
- Compliance/Privacy Issue
- Late Fee Waiver
- Other (please specify in Visit Summary/Feedback area below)
Visit Summary/Feedback
Please describe in detail your visit, if applicable.
Desired Outcome
Please list any actions you feel should be taken as a result of your visit and events described in the section above.
By checking the below box, I authorize members of Student Health Services to investigate aspects of my appointment including (but not limited to) services rendered, items billed, account balance, and my current SHS eligibility status.*
By checking the below box, I authorize members of Student Health Services to investigate aspects of my appointment including (but not limited to) services rendered, items billed, account balance, and my current SHS eligibility status.
- I authorize this form to be used by Student Health Services to address any concerns.
To submit a hard copy of the student feedback/request 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
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