Note: Email is not a secure form of communication, therefore confidentiality cannot be assured. If you need to schedule an appointment,
request a prescription refill, or send secure messages to a medical provider, please click here to go the Patient Portal.
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We invite you to share with us your thoughts/feelings regarding your experience here at the Health
Center. Your comments will receive the attention of the Health Center's administration.
This information is confidential and will not become part of your medical record. You can submit your
input online by completing the form below, OR you can
download the form, complete
it and drop it off at the Health Center or mail it to us at:
California State University, Sacramento
Student Health Center
6000 J Street
Sacramento, CA 95819-6045
Note:All fields with * are required.
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*How would you rate your overall experience at the Health Center?
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Excellent
Good
Fair
Poor
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What specific services did you receive?
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Health Education
Medical
Lab
X-Ray
Pharmacy
Other (Please specify)
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*Was your experience
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Positive
Negative, please describe:
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What suggestions do you have to improve services/care?
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| *Date of Visit
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(mm/dd/yyyy)
Click here for calendar
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Time of Visit:
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*Please give us your e-mail address so we can respond to you:
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OPTIONAL INFORMATION
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We'd like to respond to your comments. In order for us to respond, the following information
would be of assistance:
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First Name:
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Last Name:
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Address (Street, City, State,
Zip)
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