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Canadian Home Healthcare

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Client Care Survey - Canadian Home Healthcare

Client Care Survey

Client name*
First Last
Daytime phone*
Email*
Enter Email Confirm Email
As an existing client of Canadian Home Healthcare, certain email types (such as product recall information) are permissible without express consent. Please provide consent to receive additional email types by selecting from the list below.*
- Coupons
- Promotions
- Product updates
- Newsletters
- Please do not send me any of the above
Primary service location*
How would you describe your current pattern of CPAP use?*
- Always
- Frequent
- Rarely
- Never
- No longer require
Thinking of your last visit to Canadian Home Healthcare, was it?
- A scheduled appointment
- An unscheduled visit
- Do not remember
How long was your wait to see the healthcare provider?
- Less than 5 minutes
- Less than 15 minutes
- Less than 30 minutes
- More than 30 minutes
Was the administrative staff courteous and helpful?
- Yes
- No
- Do not remember
- Not applicable
Comments
Did the staff provide sufficient information to address the purpose of your visit?
- Yes
- No
- Do not remember
- Not applicable
Comments
Were you provided an opportunity to ask questions about your concerns?
- Yes
- No
- Do not remember
- Not applicable
Comments
Were the costs for products or services provided and clearly explained?
- Yes
- No
- Do not remember
- Not applicable
Comments
Were you provided with information on potential 3rd party funding sources (i.e. Assistive Devices Program, Extended Health Benefits, Government Assistance, etc.)?
- Yes
- No
- Do not remember
- Not applicable
Comments
Do you have any recommendations on how we could provide better service?
- Yes
- No
Comments
It is recommended that your CPAP unit and mask be evaluated by Canadian Home Healthcare for proper functioning on a yearly basis. How long has it been since your last follow up appointment?*
- Less than 1 year
- More than 1 year
- Do not remember
It is recommended that CPAP masks and tubing be replaced every 6 months to 1 year, filters be changed as frequently as monthly (depending on the type) and water chambers replaced as needed. Based on this information, do you require any supplies?*
- Yes
- No
Would you like to be contacted to arrange for supplies or a no charge CPAP equipment follow up?*
- Yes
- No
Contact instructions or comments
Would you recommend Canadian Home Healthcare to someone you know who is on or may require CPAP therapy?
- Yes
- No
Comments
Do you have any additional questions or comments to add?*
- Yes
- No
Questions/Comments*
Phone
This field is for validation purposes and should be left unchanged.

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Client Care Survey

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About Us
Sleep Apnea Therapy / CPAP
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Contact Us

Full Name:*
Email:*
Store*
Details:*
Comments
This field is for validation purposes and should be left unchanged.

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