Name (Optional)
First Name
Last Name
Email Address (Optional)
example@example.com
Date of Service (Optional)
-
Month
-
Day
Year
What was your most recent service experience with Regional Home Care?
*
Office Visit
In-Home Visit
Telehealth
Supply Order
Other
What was the nature of your most recent visit?
*
Initial Setup
Followup
What state do you live in?
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Other
How easy was it to order/request supplies?
Difficult
1
2
3
4
5
6
7
Very Easy
8
1 is Difficult, 8 is Very Easy
Were your supplies delivered in a timely manner?
Yes
No
Was your order correct and complete?
Yes
No
Prior to your appointment were you provided with instructions on how to initiate a TeleHealth session?
Yes
No
Not Sure
Did your visit start within 15-minutes of the appointment time?
Yes
No
What state was your office visit in?
Connecticut
Maine
Massachusetts
New Hampshire
Rhode Island
Vermont
Which office did you visit in Connecticut?
Fairfield
Rocky Hill
Other
Which office did you visit in Maine?
Bangor
Biddeford
Portland
West Bath
Other
Which office did you visit in Massachusetts?
Boston
Burlington
Danvers
Framingham
Leominster
North Andover
Randolph
South Deerfield
Townsend
West Springfield
Worcester
Other
Which office did you visit in New Hampshire?
Bedford
Other
Which office did you visit in Rhode Island?
Other
Which office did you visit in Vermont?
Rutland
South Burlington
White River Junction
Other
Was the information our staff provided during your visit correct and complete?
Not Really
1
2
3
4
5
6
7
Absolutely
8
1 is Not Really, 8 is Absolutely
Was the information provided in an easy to understand format?
Not Really
1
2
3
4
5
6
7
Absolutely
8
1 is Not Really, 8 is Absolutely
Were adequate instructions provided for the safe operation of your equipment?
Yes
No
Not Applicable
Were you informed of how to contact Regional Home Care in an "after hours" emergency?
Yes
No
I Don't Recall
Were your financial responsibilities for the equipment and supplies we provide explained to you?
Yes
No
I Don't Recall
Were your rights and responsibilities as a patient explained to you?
Yes
No
I Don't Recall
Were you provided with a copy of our patient handbook?
Yes
No
I Don't Recall
How comfortable do you feel maintaining and using your equipment?
Not Comfortable
1
2
3
4
5
6
7
Comfortable
8
1 is Not Comfortable, 8 is Comfortable
Please rate our staff's ability to answer your questions in a courteous, correct and complete manner.
Needs Work
1
2
3
4
5
6
7
Fabulous
8
1 is Needs Work, 8 is Fabulous
Please rate your overall experience with Regional Home Care.
Needs Work
1
2
3
4
5
6
7
Fabulous
8
1 is Needs Work, 8 is Fabulous
How likely are you to refer friends and family to Regional Home Care?
Not Likely
1
2
3
4
5
6
7
Very Likely
8
1 is Not Likely, 8 is Very Likely
Is there anything else you'd like to tell us about your experience with Regional Home Care?
Submit
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