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Customer Relations Feedback Form
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Please use this On-line Feedback form for messages of concerns or thanks.

* Please provide the indicated information, if you require our response.

  Type of Feedback:     
  Other: 

Patient Information

  Salutation:
* First Name:
* Last Name:  
  Address:
 
* Telephone:
   Alternate Telephone: 

Contact Information - (If you are not the patient)

Salutation:
* First Name:
* Last Name:
Address:
 
* Telephone:
Alternate Telephone
Relationship to Patient:
Other:

Summary

* Site:  
If Other, please specify:
Date of Incident:
Email Address:
 

(Your email address is requried so we can promptly respond to you)




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Absent the use of encryption, the Internet is not a secure medium and privacy cannot be ensured. Internet e-mail is vulnerable to interception and forging. Cayuga Medical Center will not be responsible for any damages you or any third party may suffer as a result of the transmission of confidential information that you make to Cayuga Medical Center through the Internet, or that you expressly or implicitly authorize the Cayuga Medical Center to make, or for any errors or any changes made to any transmitted information.
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