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Patient Engagement Survey

Your feedback is important to us.  Please complete survey below to provide honest feedback about your experience with ABC Health Care and our staff.

Survey Questions *
Survey Questions
Please only select one answer per question.
1. I was satisfied with ABC Health Care’s response to any questions, problems, concerns, and/or comments I brought to their attention.
2. I was satisfied ABC Health Care’s delivery of my items or services (scheduled time vs. actual delivery time).
3. I was satisfied with ABC Health Care’s ability to correctly bill my insurance provider(s).
4. I was satisfied with ABC Health Care’s ability to provide care, treatment, or service in a safe manner.
5. I was satisfied with ABC Health Care’s ability to protect the privacy and security of my personal health information?
6. I was satisfied ABC Health Care’s ability to assess and identify my needs?
7. I was satisfied with ABC Health Care’s willingness to include me, my family members, and/or my caregivers in the decisions about my care, treatments, and/or services?
8. I was satisfied with the information and educational materials ABC Health Care provided me regarding the care, treatment, and/or services provided?
9. I was satisfied with ABC Health Care’s entry in my residence as it pertains to respecting my property?
10. Overall, I was satisfied with the products and/or services provided to me by ABC Health Care?
Would you like to be contacted by ABC Health Care about your experience with us? *
Patient Name
Patient Name
Provide patient's name if you would like to be contacted by ABC Health Care.
Contact Phone Number
Contact Phone Number
Provide a contact phone number if you would to be contacted by ABC Health Care.