General Info:

Full Name

Phone *

Email *

Patient's Name (if different from above):

Relationship to Patient (if applicable):

Name of Care Provider

By checking this box, I consent to receive calls and text messages from Epic Home Healthcare regarding my inquiries, appointments, or services I have requested. I understand that these communications may include automated, pre-recorded, or AI-generated voice calls and messages.

Message frequency may vary. Standard message and data rates may apply. I may reply HELP for assistance or STOP to opt out of future messages and calls at any time. Consent is not a condition of receiving care or services. A representative may contact me shortly regarding my inquiry.

Service Experience:

How satisfied are you with the overall quality of service provided?

How would you rate the professionalism and friendliness of our staff?

Did our staff arrive on time for scheduled appointments?

Were your (or the patients) healthcare needs met effectively?

How would you rate the communication between you and our staff?

Specific Services:

Please rate the following aspects of the specific

services you received:

Live-In Care

Personal Hygiene Care

Companionship

Mobility Assistance

Respite Care

Pediatric Care

Dementia Care

Worker's Compensation Care

Private Duty Nursing – RN, LVN, LPN & CNA

Veterans Care

Additional Feedback:

What do you appreciate most about our services?

What areas do you think need improvement?

Anything else you would like to add

Do you have any suggestions on how we can enhance our services?

Would you recommend us to friends or family in need of home healthcare services?

Yes