Healthcare Service Transfer Survey
Please provide your feedback on your recent experience with the transfer of healthcare services. Your responses will help us improve our processes.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Healthcare Service Transfer
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
From which healthcare provider or facility were you transferred?
*
To which healthcare provider or facility were you transferred?
*
How would you rate your overall experience with the transfer process?
*
1
2
3
4
5
Please rate the following aspects of your service transfer experience:
*
Rows
Very Poor
Poor
Fair
Good
Excellent
Communication between providers
1
2
3
4
5
Timeliness of the transfer
6
7
8
9
10
Clarity of information provided
11
12
13
14
15
Support before the transfer
16
17
18
19
20
Support after the transfer
21
22
23
24
25
What challenges, if any, did you experience during the transfer?
Lack of communication
Delays in transfer
Incomplete medical records
Unclear instructions
Difficulty accessing new provider
Other
Did you feel adequately informed about the transfer process?
*
Yes
No
Somewhat
Would you recommend this transfer process to others?
*
Yes
No
Not Sure
Please provide any suggestions for improving the healthcare service transfer process.
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