Medical Provider Feedback

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please provide us feedback about the Bag It bag you provide to your patients. Thank you!

Company Name

Your first name

Your last name

Email Address

Rate based on your experience with patients & co-survivors using Bag It

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Unable to Gauge

Patients are more informed; ask better questions; seem more comfortable speaking up

Patients are more organized

Patients seem to cope better/worry less

Bag It is helpful to patients, co-survivors (feedback you receive)

Clear selection

Can you tell if someone is using their Bag It bag?

Yes

Clear selection

If yes, how can you tell?

How does Bag It make your job easier?

When do you think is the best time to give the bag out?

What is the single best benefit or component of the bag?

What would you change, add or delete?

Comments

Please indicate if we can use your comments in promotional/other materials.

Yes, you can use my comments WITH my name

Yes, you can use my comments without my name

No, please don't use my comments

Clear selection

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy