Help us ensure our self-advocacy tool is effective.
Let us know about your experience using
the patient bill of rights.
Thank you for helping us work towards
a gold standard of care and drive change. 

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* 1. Contact Information (Your information will not be shared.)

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* 2. When did you have your ostomy or continent diversion surgery?

Date 

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* 3. When did you use our patient bill of rights?

Date 

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* 5. Where did you use our patient bill of rights? (type of facility, location)

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* 6. What was your story? (Problem? Outcome? Would you do it differently next time?)

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* 8. Do you think the situation was improved?

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* 9. How did you use the patient bill of rights?

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* 10. Were the patient bill of rights useful?

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* 11. Would you share these patient bill of rights with someone else?

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