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Consumer Questionnaire Survey

Name*

Date

Which services did you receive today? Required
Was the reason for your call addressed Required
On a scale of 1 to 5 (1 being Poor and 5 being Excellent) rate your service today? Required
Are you more knowledgeable of your healthcare options now than before your call/visit with a representative from Coalition for Healthcare Required
If YES, on a scale of 1-5 (1 being Poor and 5 being Excellent) rate your knowledge Required
Are you more knowledgeable now than before of how to use your Health Insurance before your call/visit with a representative from Coalition for Healthcare? Required
If YES, on scale of 1-5 (1 being Poor and 5 being Excellent) rate your knowledgeable now Required
Would you recommend the Coalition for Healthcare to others needing services? Required

Comments: Use this space to provide additional comments.

Signature 

Date

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