UberCENTRAL Support Request

Use this form to complete a Questionnaire for our Rehab Success Stories!

Submittor Details
Submittor Name*

Enter your name.
Submittor Email*

Please enter your Alaris email so that we may contact you regarding this submission if need be.
Questionnaire Details
Facility*
Please select a facility.
Name of Patient*

Enter the name of the patient.
Name of Therapist*

Enter the name of the therapist.
Date of Admission*
MM slash DD slash YYYY

Select the date that the patient was admitted.
Date of Discharge*
MM slash DD slash YYYY

Select the date that the patient was discharged.
Hospital Patient was Discharged From*

Enter the name of the hospital that the patient was discharged from.
Primary Care Physician*

Enter the name of the primary care physician.
Ortho Physician/Surgeon (if applicable)

Enter the name of the ortho physician/surgeon (if applicable).
Brief narrative from therapist describing the reason this resident has been identified as a success story for our location:*
Diagnosis Related to Therapy:*
Please select the primary reason.
Questions for the Patient
1) Did you have a goal you wanted to achieve when you started (i.e. personal – dance at family wedding, get home for the holidays’ etc.)*
2) Was there a particular person in the member center that you felt went above and beyond to help you reach your goals?*
3) Had you been to a rehab center in the past and if so how did would you compare your experience?
4) Please provide a short quote / statement we can use about your rehabilitation?*
(If patient is unable to give statement, please speak with caregiver or family member).
Image Upload
Submisson Image*
Accepted file types: jpg, jpeg, png, gif.
Select the picture that you would like to submit.
Photo Details
Please include names of all people from Left to Right that are featured in the photo, along with their positions.
Photography Consent*
Everyone featured in this photo agrees to have their photo posted on the Alaris Health Facebook, Twitter and Instagram pages as well as the Alaris Health website.
- Yes
- No

UberCENTRAL Support Request

Submittor Details

Questionnaire Details

Questions for the Patient

Image Upload