Exit

Please Tell Us How Our Services Meet Your Needs

Please mark the rating that best represents your experience for each of the questions below.  If you had no experience with a particular item, mark (N/A) not applicable.  Please comment on any positive or negative experiences you may have had.  We appreciate your opinions and thank you for your time. 

Question Title

* 1. What is the patient's LAST name?

Question Title

* 2. What is the patient's FIRST name?

Question Title

* 3. What was the patient's Unit of Care Code? (2 or 3 letters at bottom of page under bar code. Examples would be RP, SCI, BIR or STR)

Question Title

* 4. Patient Information

Question Title

* 5. Overall experience with the services requested

Question Title

* 6. Likelihood of you recommending services to others

Question Title

* 7. Rooms/ Accommodations

Question Title

* 8. Nutritional and Dietary Services

Question Title

* 9. Nursing Services

Question Title

* 10. Physician Services

Question Title

* 11. Case Management

Question Title

* 12. Therapies (Physical, Occupational, Speech, Recreational & Psychology)

Question Title

* 13. Staff Professionalism (Showed Knowledge of their Skills and Respected your Privacy and Dignity)

Question Title

* 14. Staff Courtesy

Question Title

* 15. What is your relationship to the patient?

Question Title

* 16. Do you have any other comments, questions, or concerns?

( Privacy & Cookie Notice

T