Client Satisfaction Survey

Client Satisfaction Survey
Are you a client or caregiver/family member?

ClientClient caregiver/family member
{areYou6}

First NameLast Name
Client email
Collect for account management purposes & to communicate updates
In which province do you (or the client) reside?

AlbertaSaskatchewanManitoba
If a friend or family member ever needed oxygen services, how likely are you to recommend Careica Health?

0

1

2

3

4

5

6

7

8

9

10

0 is Not likely, 10 is Very likely
Which Careica staff member did you interact with most recently?
Please enter their name, as best as you know it.

Please consider your most recent interaction with Careica Health when answering the following questions:

	Yes	No	I don't know	Not applicable
Do you feel well informed about your oxygen treatment?
Do you understand the health benefit of using oxygen?
Do you think using oxygen will/does improve your quality of life?
Did the Careica employee do a good job explaining how to operate your back-up oxygen, if required?
Overall, were you satisfied with the service you received from Careica Health?

What was the main reason for your score?
Is there anything we could have done to make your experience with us even better?

YesNo
What could we have done to make your experience with us even better?
Would you like to be entered in our monthly survey draw for a $100 VISA gift card? (clients only, not caregivers)

Yes please!No thank you
Please provide your contact details for the monthly survey draw. Please be assured that your survey responses will remain confidential.
Name

First NameLast Name
Email
example@example.com
Phone Number
10 digit phone number
Client number:
OFFICE USE ONLY
Should be Empty: