PHC/FC/CAS Client Satisfaction Survey
You have recently received services from AtHome Solutions Healthcare. We want to ensure that we continue to provide quality care. You can help us improve our services by rating our service by responding to the following questions. Please return this form to our agency.
Rating Questions
Excellent
Good
Average
Fair
Poor
Would you refer a friend or family member to our agency? If No, please indicate reason.
Comments:
Signature (Optional):
Date:
Please return this form to the agency. Your signature is optional. May we contact you regarding your response to this survey
Thank you for completing this form.
[field id="excellent_a"]
[field id="good_a"]
[field id="Average_a"]
[field id="fair_a"]
[field id="poor_a"]
[field id="excellent_b"]
[field id="good_b"]
[field id="Average_b"]
[field id="fair_b"]
[field id="poor_b"]
[field id="excellent_c"]
[field id="good_c"]
[field id="Average_c"]
[field id="fair_c"]
[field id="poor_c"]
[field id="excellent_d"]
[field id="good_d"]
[field id="Average_d"]
[field id="fair_d"]
[field id="poor_d"]
[field id="excellent_e"]
[field id="good_e"]
[field id="Average_e"]
[field id="fair_e"]
[field id="poor_e"]
[field id="excellent_f"]
[field id="good_f"]
[field id="Average_f"]
[field id="fair_f"]
[field id="poor_f"]
[field id="poor_f"]
[field id="radio_field"]
[field id="reason"]
[field id="comment"]
[field id="date"]
[field id="radio_one"]
