PATIENT SURVEY

Thank you for giving us the opportunity to serve you. We appreciate your feedback and are committed to listening to our customers.

Name
Email
Device Serial #
Phone
Practice Name

Rate our service level and your experience using the monitor and its accessories

General satisfaction with Preventice
Ability to contact Preventice at 888.500.3522
Attention given to your comments
Knowledge, professionalism and courtesy of representatives
Comfort of wearing your monitor
Delivery and set up of your monitor
Shipment of supplies for the length of your monitoring period
Value of the instruction manual included in your box



Additional Comments:


I here by authorize Preventice Solutions, Inc. to use, reuse, publish or republish my name in light of any communication I made and photographic likeness in all forms and all media for advertising, marketing, and any other lawful purposes. I release and discharge Preventice Solutions, Inc. from any and all claims and demands that may arise out of or in connection with the use of photographs, name or likeness, including without limitation any and all claims for libel or violation of any right of publicity or privacy. I have read this release and fully understand its contents, and I reserve the right to revoke this release upon written request to: Preventice Solutions, Inc.
I want to share my experience, but do not want it posted online or used.