PATIENT STORY SUBMISSION
Thank you for taking the time to share your experience with Northland Health Centers. Your story may help others in our communities understand the care and services available to them.
Your Story:
*
Permission to Share Your Story:
Please select all statements that apply.
I give Northland Health Centers permission to share my story (web, social, newspaper, etc.)
I am willing to consider participating in a video or interview.
The Northland Health Centers marketing team may contact me about my story.
About You
Providing your name allows us to recognize you when sharing your experience. However, providing your name is completely optional. You may choose to have your story shared anonymously.
Name
First Name
Last Name
NHC Site Visited:
Please Select
Bismarck
Bowbells
McClusky
Minot
Ray
Rolette
St John
Turtle Lake
Email Address:
example@example.com
Phone Number:
Format: (000) 000-0000.
If your story is shared, how would you like to be identified?
You can use my name (Ex. "John D")
You can use the location I was seen at (Ex. Minot, ND)
Share my story anonymously
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