Generic Veterans Health Administration Customer Satisfaction Surveys

Would you like to brighten someone's day with a hand-delivered message? Let a hospitalized friend, family member or colleague know you're thinking about them. To send a free e-mail greeting to a patient at the Canandaigua VA Medical Center, fill out the form below.
Information you provide will not be used for any other purpose.

Top of Form

All fields marked with an asterisk are mandatory.
Patient's First Name	*
Patient's Last Name	*
Patient's Middle Initial
Patient's Location	*
Your First Name	*
Your Last Name	*
Personal Message	*
Please Note: Patient e-mail greetings will not be delivered if an intended recipient has requested nondisclosure of status as a patient. Bottom of Form

Important Information & Disclaimers
	Please do not include any private patient health information in the e-mail.
	Federal and state privacy laws regarding protection of health information may prevent delivery of some e-mail messages.
	Personnel of the Canandaigua VA Medical Center are not permitted to discuss protected health information with anyone other than a patient or the patient's legally authorized representative.
	E-mails must be sent by noon, Monday through Friday, to be delivered the same day.
	E-mails received over the weekend will be delivered on the following Monday.
	There may be delays in delivery for e-mails received during holidays.
	E-mail received after the intended recipient has been discharged will not be delivered.
	The VA Medical Center at Canandaigua cannot guarantee delivery of an e-mail greeting.
	Acceptance of an e-mail by this site does not mean that the intended recipient is now nor was previously a patient of the Canandaigua VA Medical Center.
	All undeliverable e-mails will be destroyed by the Medical Center.
	The patient e-mail greeting service is set up only to receive messages. Outgoing messages cannot be sent.

OMB Approved No. 2900-0570

Estimated Burden Avg. 5 min.

VA Form 10-150039(WS) (pending OMB approval)