Recommend a Provider

Introduction

Thank you for recommending someone who participated in your care. Please provide as much information about this individual or facility as you can. The following is a sample of how the recommendation will be placed on our website:

This recommendation is for Jane Doe, MD of the City Women's Health Clinic, 132 Main Street, Anytown, MN. Dr. Doe was absolutely wonderful in helping us through the most difficult days of our lives. Although she couldn't tell us why this happened she clearly understood our suffering and gave us all the time we needed to ask questions and express our thoughts. -- Tom & Mary B., Anytown, MN

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* 1. Please tell us about you......

Your Name *

Company:

Address:

Address 2:

City/Town: *

State: *

ZIP:

Country: *

Email Address: *

Phone Number: *

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* 2. Please add my recommendation and

List my first name and last initial and city, state ( i.e. Mary P, Anytown, MN)

List as anonymous with city and state. (i.e. Anonymous, Anytown, MN)

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* 3. This recommendation is for.....

Obstetrician

Maternal Fetal Medicine Specialist/Perinatologist

Family Physician

Midwife

Labor/Delivery Doula

Loss Doula

Nurse - Hospital

Nurse - Clinic

Nurse Practitioner/Physician Assistant

Social Worker

Therapist/Counselor

Spiritual Leader/Clergy

Ultrasound Technician (Sonographer)

Hospital Birthing Unit

Non-hospital Birthing Center

Author of Book/Publication/Blog etc. You Found Especially Helpful

Other (please specify)

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* 4. I would like to recommend

Name: *

Company:

Address:

Address 2:

City/Town: *

State: *

ZIP: *

Country: *

Website/Email Address:

Phone Number:

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* 5. Please tell us why you would recommend this individual or birthing hospital/center.

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* 6. May we send a note to the individual/facility you are recommending to thank them for a job well done and to let them know your recommendation will appear on our website?

Yes

Comments

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* 7. May we contact you if we have any questions about this recommendation?

yes, by phone

yes, by email

yes, by either email or phone

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* 8. I agree to have this recommendation placed on the Star Legacy Foundation website and I understand that my comments may be edited for clarity and length.

I agree