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)

Respiratory supplies (i.e. oxygen, cough support, nebulizers)

Other (please specify)

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* 2. Is this your first time receiving a package from us?

Yes

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* 3. Did the supplies arrive in the time frame that you expected?

Yes

If no, please explain:

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* 4. Have you encountered any problems with the product(s) you were provided?

Yes

If yes, please explain:

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* 5. I received instructions on the proper use of the equipment or supplies from either my healthcare provider or CHC Solutions.

Yes

If no, please explain:

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* 6. How would you rate the Customer Service Representative who handled your order?

	Excellent	Very Good	Good	Poor	Very Poor	N/A
Product knowledge:	Product knowledge: Excellent	Product knowledge: Very Good	Product knowledge: Good	Product knowledge: Poor	Product knowledge: Very Poor	Product knowledge: N/A
Financial responsibilities explanation:	Financial responsibilities explanation: Excellent	Financial responsibilities explanation: Very Good	Financial responsibilities explanation: Good	Financial responsibilities explanation: Poor	Financial responsibilities explanation: Very Poor	Financial responsibilities explanation: N/A
Friendly and accommodating:	Friendly and accommodating: Excellent	Friendly and accommodating: Very Good	Friendly and accommodating: Good	Friendly and accommodating: Poor	Friendly and accommodating: Very Poor	Friendly and accommodating: N/A

If you rated any of the previous as poor or very poor, please explain:

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* 7. How would you rate your overall experience with us?

	Excellent	Very Good	Good	Poor	Very Poor
Rating:	Rating: Excellent	Rating: Very Good	Rating: Good	Rating: Poor	Rating: Very Poor

Why did you give this rating?

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* 8. How likely is it that you would recommend CHC Solutions to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

CHC Solutions Patient Care Survey

Question Title

* 1. Which type of products did you receive from us? (Check all that apply)

Question Title

* 2. Is this your first time receiving a package from us?

Question Title

* 3. Did the supplies arrive in the time frame that you expected?

Question Title

* 4. Have you encountered any problems with the product(s) you were provided?

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* 5. I received instructions on the proper use of the equipment or supplies from either my healthcare provider or CHC Solutions.

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* 6. How would you rate the Customer Service Representative who handled your order?

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* 7. How would you rate your overall experience with us?

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* 8. How likely is it that you would recommend CHC Solutions to a friend or colleague?

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* 9. Other Comments: