I am a
--select-- Patient of Health Care Plus' (Home Health) Family member of a Health Care Plus patient Patient of Marden Rehab's (Outpatient Physical Therapy) Family member of a Marden Rehab patient Patient of a Nursing Facility with Marden Rehab Family member of a Skilled Nursing Facility Patient Skilled Nursing Facility with Marden Rehab Physician Office Other referral source

1. Overall, the Medical Services received were / are
--select-- a. Excellent b. Above Average c. Average d. Below Expectations

Please Rate Our...

2. Professional Treating Staff
--select-- a. Excellent b. Above Average c. Average d. Below Expectations

3. Administrative Staff
--select-- a. Excellent b. Above Average c. Average d. Below Expectations e. Not Applicable

4. Management Staff
--select-- a. Excellent b. Above Average c. Average d. Below Expectations e. Not Applicable

5. Communication
--select-- a. Excellent b. Above Average c. Average d. Below Expectations

Please Comment on our timeliness and accuracy...

6. Are we responsive to your concerns?
--select-- a. Always b. Most of the time c. Some of the time d. Never e. Not Applicable

7. Are the billing of services timely?
--select-- a. Always b. Most of the time c. Some of the time d. Never e. Not Applicable

8. Are the billing of services accurate?
--select-- a. Always b. Most of the time c. Some of the time d. Never e. Not Applicable

9. Are treatments conveniently scheduled?
--select-- a. Always b. Most of the time c. Some of the time d. Never e. Not Applicable

Please Comment on choosing Marden or Health Care Plus...

10. If you were referred to us, who referred you?
--select-- a. Physician b. Social Worker c. Discharge Planner d. Not Sure

11. Had you heard about us before we provided services?
--select-- a. Yes b. No c. Not Sure

12. If yes, how did you hear of us?
--select-- a. Returning patient b. Yellow Pages c. Internet d. Advertisement in my doctor's office e. Advertisement in the news paper f. Recommended by friend / family member g. Recommend by a health care professional h. Not Applicable

13. Please rate your overall experience with us.
--select-- a. Excellent b. Above Average c. Average d. Below Expectations

Please provide your recommendations and comments...

14. Would you recommend Marden or Health Care Plus?
--select-- a. Yes b. Maybe c. No d. Not Sure

15. Would you like us to contact you?
--select-- a. Yes b. No

16. If "Yes", please provide your contact information.
Name:

Phone Number:

e-mail Address:

17. Please provide any additional comments.