CareSouth Carolina COMMENT FORM                                                     Date:  

How would you describe yourself (check all that apply):

Patient    Family Member/ Guardian of Patient    Community Member    Other

Your Name:      

Contact Phone:      home  cell  work

Other Phone:         home  cell  work

Do you wish to be contacted about your comment?    yes  no

If yes: what is the best time to contact you?     

            what is the best way to contact you?     telephone  email  other:

If your comment is related to one of our medical centers, please let us know which one:

Bennettsville  Bennettsville Pediatrics  Bishopville                 Cheraw      Chesterfield

Hartsville       Hartsville Pediatrics      Hunt Family Practice  Lake View  McColl

Society Hill

How would you describe your comment?

Complaint  Compliment  Suggestion  Question  Other: 

YOUR COMMENT: