Submit Your Referral

Satisfaction Survey

HOMELINK appreciates being able to serve you as a patient. Please fill in the answers to the questions below. Those marked with an * are mandatory fields.
First Name: *     Last: *
Email Address:    
Your location: *
City State    
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Goods and services that you received, please select: *
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Name of the company that provided services:
Date you received your equipment: *
RadDatePicker
Open the calendar popup.

Did you have contact with a HOMELINK representative during the process of receiving equipment or services? If so, please complete the survey below. If not, please skip ahead to "Other Comments".
Please rate the HOMELINK contact:
 
Poor
Average
Fair
Good
Exceptional
1.) Professional, Knowledgeable
2.) Prompt follow through
3.) Courteous
4.) Clear Communication
5.) Trustworthy
6.) Fully attentive to your needs

Other comments and/or suggestions:


Thank you for taking the time to let us know how we can improve our service. Your feedback is important to us!