Thank you for choosing Charak!

Please answer the questions below so that we can continue to improve and help spread hope! All surveys are submitted anonymously and are simply used to improve our services.

Please correct the errors described below.

Are you currently receiving treatment from Charak Center?

Yes No

How satisfied are you with your overall experience with Charak?

Very Satisfied Somewhat Satisfied Neutral Somewhat Dissatisfied Dissatisfied

Do you feel like you are an active participant in your treatment?

Yes No Somewhat

How satisfied are you with our registration process?

Very Satisfied Somewhat Satisfied Neutral Somewhat Dissatisfied Dissatisfied

How satisfied are you with your treatment provider at Charak?

Very Satisfied Somewhat Satisfied Neutral Somewhat Dissatisfied Dissatisfied

How likely are you to recommend Charak?

Very Likely Likely Neutral Not Likely

Are you currently, or have you been, utilizing CCHW Pharmacy?

Yes No

How did you first hear about Charak?

TV Commercial Facebook Instagram Twitter Referral Other: (If other, Describe below)

Other:

Did you know that CCHW Pharmacy offers free delivery, will fill your family's prescriptions and always has mental health medications in stock?

Yes, I knew that No, I did not know that

Additional Comments:

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide