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Kidney Care Connections

Kidney Care Connections

Center Visit Survey

Please take a moment to tell us about your
Center visit.

*1.  


2.
Question - Not Required - Was the person who visited the lawmaker or a member of their staff?


3.  


4.
Question - Not Required - Was the visitor a Federal or State lawmaker?


5.
Question - Not Required - What is the lawmaker's title?






6.  


7.  


*8.  


9.  


10.

11.  


12.
Question - Not Required - Visit Date




13.
Question - Not Required - Was a DPC Patient Ambassador involved in the visit?


14.
Question - Not Required - If not, do you have a patient who would make a good Ambassador?


15.
Question - Not Required - Do you have photos of the event? If so, please email photos to Amy Bogan at Amy.Bogan@davita.com.


16.

17. Your Name and Contact Information

 

Name:

 

 
   

 

 

 

If you respond and have not already registered, you will receive periodic updates and communications from KidneyCareConnections.org.

 

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