Thank You Submission Form

Fill out the form below to recognize a department or staff member at Carroll County Memorial Hospital for going above and beyond. Hearing the words "thank you" from a patient or family member is often more meaningful to our team members than any other type of reward. *Disclaimer: Information left on this page may be viewed by others.*

First and Last Name (if known) of Staff Member(s)

Department/Location (if known)

Describe a specific situation or story that demonstrates how a CCMH staff member or department made a meaningful difference in your care.*

Please tell us about yourself. We may contact you if we need more information about your nomination or if your staff member has been selected to receive a special award.

Your Name:

Phone: (required)*

Email:

May we share this as a public testimonial? (Additional releases of information may be required due to HIPAA requirements. Please make sure to include your contact information above.)*

Yes