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Customer Feedback Form
Share your experience with Prestige Senior Home Care and rate your caregiver’s service.
Are you the client or a family member?
*
Client
Family Member
Client Name
*
Caregiver Name
*
Date of Service
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate the following aspects of your caregiver's service:
Professionalism
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Compassion
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Communication
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Respect
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
Overall Satisfaction
*
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
What did Prestige or the caregiver do well? Tell us a personal story!
Include any photos or videos you have from our care!
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What could be improved?
Did our services meet your expectations?
*
Yes
No
Partially
Would you recommend Prestige Senior Home Care to others?
*
Yes
No
Not Sure
Would you like us to follow up with you regarding your feedback?
*
Yes, please contact me
No, follow-up is not needed
If you would like follow-up, please provide your contact information (phone or email):
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