Did Hospice promptly respond to your initial contact?

Yes

No

NA

Were you provided information in a prompt and timely manner?

Yes No NA

Option One

Option Two

Was Hospice staff helpful and consistent with information at all times?

Yes

No

NA

Were any issues or concerns resolved to your satisfaction?

Yes

No

NA

In the future would you recommend Hospice of the North Country?

Yes

No

NA

Are you a:

Vendor

Business

Facility

Organization

Patient

Family

Other

Name

First Name

Last Name

Date

MM

DD

YYYY

Phone

(###)

###

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