Health Support Feedback Survey
Please share your feedback on the health support services you received. Your input helps us improve our support and care.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What type of health support did you receive?
*
Please Select
Medical Consultation
Mental Health Counseling
Nutritional Advice
Physical Therapy
Other
How did you access the health support service?
*
In-person
Phone
Video Call
Online Chat
Other
Please rate the following aspects of the health support you received:
*
Rows
Excellent
Good
Fair
Poor
Ease of scheduling
1
2
3
4
Communication with staff
5
6
7
8
Professionalism of provider
9
10
11
12
Clarity of information provided
13
14
15
16
Effectiveness of support
17
18
19
20
How satisfied are you with the overall health support experience?
*
Not satisfied
1
2
3
4
Very satisfied
5
1 is Not satisfied, 5 is Very satisfied
Would you recommend our health support services to others?
*
Yes
No
What did you find most helpful about the health support you received?
What could we improve in our health support services?
Any additional comments or suggestions?
Submit Feedback
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