Telehealth Service Feedback Form
We value your feedback to improve our telehealth services. Please take a moment to share your experience.
Full Name
First Name
Last Name
Email Address
example@example.com
Date of Telehealth Appointment
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate the quality of the telehealth service?
1
2
3
4
5
How easy was it to connect to the telehealth session?
Very Easy
Easy
Neutral
Difficult
Very Difficult
Did the telehealth service meet your expectations?
Yes
No
Somewhat
What did you like most about the telehealth service?
What improvements would you suggest?
Would you recommend our telehealth service to others?
Definitely
Probably
Not Sure
Probably Not
Definitely Not
Submit
Should be Empty: