Home Sales Customer Satisfaction Survey Form

Home Sales Customer Feedback Survey

Please take a moment to tell us how we did!
Patient Name*

First NameLast Name
About Your Daavlin Representative
How did you hear about Daavlin?*
Did you use our free insurance processing service?

YesNo
What is the name of your insurance company?
(e.g. Medicare, Anthem, etc.)

Please tell us how your Daavlin representative did:*

How would you rate your overall satisfaction with your Daavlin representative?*

1 = Low, 5 = High
Why did you choose to purchase your medical device from Daavlin?
About Our In-Network DME Distributor

Sometimes Daavlin is not contracted with a particular insurance, yet we are able to help our customers gain access to their in-network insurance benefits by working together with one of our approved DME (Durable Medical Equipment) Distributors.
Did your order process through a distributor?

YesNo
Name of Distributor

How would you rate your overall satisfaction with your distributor?

1 = Low, 5 = High
In your opinion, should Daavlin continue to use this distributor?
About Your Daavlin Home Product
Please select the device you received:*

DermaPal1 Series4 Series7 SeriesUV SeriesAquexSAD LightM Series
Was the packaging and delivery of your Daavlin product satisfactory?

YesNo
If you answered "no" to the above, please explain why:
How would you rate your overall experience with Daavlin?*

1 = Low, 5 = High
Is there anything we can do to improve our products, website and/or services?
If you wish to receive a response from Daavlin about your comments or questions, please include your name, company (if applicable), phone, and email.
FRM-00105 [1]
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Home Sales Customer Feedback Survey