Cottage Grove Guardian Angel nomination

Form Description

Did a caregiver make a meaningful difference in your visit to or stay at PeaceHealth Cottage Grove Community Medical Center?

Recognize your caregiver(s) and we'll honor your Guardian Angel(s) with a special presentation. They'll receive a certificate and a specially-designed lapel pin in recognition of the exceptional care they provided.

Directions

Fill in the information below. Use the scroll bar on the right to move down the page. When finished, click the Save button located at the bottom of the form. Questions marked with a red * require a response.

I/We would like to recognize:

Guardian Angel First Name

Guardian Angel Last Name

(Department, physician, nurse or other caregiver)

I or a loved one received exceptional care in:

Month/year

At:

Department or clinic

My/our story:

Sharing my story:

* PeaceHealth may share my story in newsletters and online.

Yes

I'd like someone to contact me to share my story.

My information:

* First name

* Last name

Address:

* Street Address

* City

* State

Zip Code

E-mail:

* E-mail address

Phone:

* Home

(Include area code)

Cell

Work

* Best number to reach you

Home

Cell

Work

When you honor a caregiver at PeaceHealth Cottage Grove Community Medical Center Foundation, they'll receive an angel wings lapel pin and certificate in a special ceremony.