Medical Equipment Application Survey
Help us assess your needs and experience with medical equipment by completing this survey.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please select your primary reason for needing medical equipment:
*
Mobility assistance
Respiratory support
Monitoring devices
Daily living aids
Other
Which type(s) of medical equipment do you currently use? (Select all that apply)
Wheelchair or mobility scooter
Oxygen concentrator or respiratory device
Blood pressure monitor
Glucose meter
Bathing or toileting aids
Other
Please rate your satisfaction with the medical equipment you currently use:
*
1
2
3
4
5
Please indicate your agreement with the following statements about your current equipment:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The equipment is easy to use
1
2
3
4
5
The equipment meets my needs
6
7
8
9
10
I received adequate support and training
11
12
13
14
15
The equipment is reliable
16
17
18
19
20
Are there any additional features or types of equipment you need?
How did you learn about our medical equipment application program?
Please Select
Healthcare provider
Hospital or clinic
Friend or family
Online search
Social media
Other
Would you recommend our medical equipment program to others?
*
Yes
No
Please provide any additional comments or suggestions:
Submit Survey
Should be Empty: