QUICK SURVEY

Thank you for your interest in our quick survey. Your feedback will help us to provide you and your loved ones the highest quality healthcare possible. Your name and e-mail address are optional and will be kept confidential.

First Name		Last Name
City		State	Alabama Alaska American Samoa Apo/Fpo - Miami Apo/Fpo - New York Apo/Fpo - San Francisco Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Fd States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
E-mail
Your e-mail address will be kept confidential and you will not be put on any mailing list.
How did you hear about us?		Please select one... Search Engine Healthcare Provider Provident Senior Health Employee Online Yellow Pages Phone Book Friend or Acquaintance
Your age?		Please select one... Under 21 21 - 55 56 - 60 61 - 65 66 - 70 71 - 75 76 - 80 81 - 85 Over 85
Medicare?		yes   no
Medicaid?		yes   no
What provider qualities do you value most?		Education Experience Personality Office Location Office Hours Payment/Insurance Options
Are you satisfied with your provider's communication with the patient?
		yes   no
Are you satisfied with your provider's communication with family and other caregivers?
		yes   no
Does your provider follow the patient's care to the hospital or clinic?
		yes   no
Does your provider follow the patient's care to the nursing home?
		yes   no
Does your provider follow the patient's care to the assisted living facility?
		yes   no