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CHC Solutions Patient Care Survey
Your feedback is very important to us. Please take a moment to complete the survey. Thank you in advance.
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1.
Which type of products did you receive from us? (Check all that apply)
Wound care supplies (i.e. bandages, gauze, dressings, gels)
Urological supplies (i.e. catheters, drainage collectors)
Ostomy supplies (colostomy, urostomy, ileostomy)
Incontinence supplies (i.e. adult diapers/liners, underpads)
Diabetic care supplies (i.e. continuous glucose monitors, test strips, lancets)
Oral Nutritional supplies (i.e. oral nutritionals)
Enteral Nutritional Supplies (i.e. tube feeding supplies, feeding pumps. formula)
Specialty items (i.e. hospital beds, Hoyer lift, wheelchair, bath safety)
Other (please specify)
2.
Is this your first time receiving a package from us?
Yes
No
3.
Did the supplies arrive in the time frame that you expected?
Yes
No
If no, please explain:
4.
Have you encountered any problems with the product(s) you were provided?
Yes
No
If yes, please explain:
5.
I received instructions on the proper use of the equipment or supplies from either my health care provider or CHC Solutions, Inc.
Yes
No
If no, please explain:
6.
How would you rate the customer service representative who handled your order?
Excellent
Very Good
Good
Poor
Very Poor
N/A
Product knowledge:
Excellent
Very Good
Good
Poor
Very Poor
N/A
Financial responsibilities explanation:
Excellent
Very Good
Good
Poor
Very Poor
N/A
Friendly and accommodating:
Excellent
Very Good
Good
Poor
Very Poor
N/A
If you rated any of the previous as poor or very poor, please explain:
7.
How would you rate your overall experience with us?
Excellent
Very Good
Good
Poor
Very Poor
Rating:
Excellent
Very Good
Good
Poor
Very Poor
Why did you give this rating?
8.
On a scale of 0 to 10,
How likely is it that you would recommend CHC Solutions to a friend or colleague?
0 for Not at all likely, 10 for Extremely likely
Not at all likely
Extremely likely
0
1
2
3
4
5
6
7
8
9
10
9.
Other Comments:
10.
Contact Information (Optional)
First and Last Name
Phone Number
Email
