VGM HOMELINK - Patients

September 6, 2010

• PROVIDER LOCATOR
• SATISFACTION SURVEY
• CONFIRMATIóN DE ENCUESTA
• ORDER PICKUP FORM
• QUICK ORDER

SATISFACTION SURVEY

HOMELINK appreciates being able to serve you as a patient. Please fill in the answers to the questions below. A * indicates a mandatory field.

First Name: * Last: *

Email Address:

Your Location: *

City: State:

Goods and services that you received, check all that apply

Equipment
Supplies
Nursing Supplies
Physical Therapy/Occupational Therapy
Nursing Evaluation
Sleep Study
Supplies (IE: for wounds; surgical care; sleep equipment; etc.)
Transportation
Other:

Name of the company that provided services:

Date you received your equipment:

(Month/Date/Year format, EG: 00/00/00)

Click on the boxes below that best describes the service that you received:

	Poor	Fair	Good	Exceptional
1.) Delivery was prompt, as scheduled
2.) Delivered items were in good condition
3.) Delivery person was helpful
4.) Delivery person was professional, courteous
5.) Overall rating of the company
6.) Overall rating of their service
7.) Dealers chosen are reliable, professional and prompt

Did you have contact with a Homelink representative during the process of receiving equipment or services? If so, please complete the survey below. If not, please skip ahead to "Other Comments".

Please rate the Homelink contact:

	Poor	Fair	Good	Exceptional
1.) Professional, Knowledgeable
2.) Prompt follow through
3.) Courteous
4.) Clear Communication
5.) Trustworthy
6.) Fully attentive to your needs
Other comments and/or suggestions:

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Thank you for taking the time to let us know how we can improve our service. Your feedback is important to us!

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