Referring Provider Feedback

Referring Provider Feedback

Please use the form below to let us know if we have met your needs or how we may better serve you and your patients.  The form below can also be used to commend the care or service of one staff member in particular.


Please indicate the Swedish Campus your patient visited, if applicable.

Other location or clinic:

Provider(s) who treated
 your patient:

**Please Note.  This is not a secure form.  Do not include patient identifiers.

Please evaluate your satisfaction with the following items during your visit.

Rate the Provider Referral Line Service:

Were you contacted by the Patient Access Team within 24-48 hrs after your initial request?:


Were you satisfied with the timeline of the scheduled appointment?:

Was our staff courteous and helpful?:

Did you receive a follow up communication from the referred provider in a timely manner?:

Would you recommend our Provider Referral Line to other colleagues or organizations?:

Would you like to tour our facilities or meet with a specific provider?:


May we contact you: