For Facilities Form

* Required Information

Your Full Name *

Company Name *

Your Position in the Company *

Company Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

What position(s) in your company would you like to fill? Please also provide the qualifications and/or the number of staff you need *

How do you prefer to be contacted? *

Best time to call *

Preferred Date

Preferred Time

Comments

Preferred Date

Preferred Time

Client Satisfaction Survey

Please rate the quality of the services you received from WholeCare Medical Staffing

Excellent

Good

Fair

Poor

Please rate the staff in terms of efficiency

Excellent

Good

Fair

Poor

Please rate your overall satisfaction with service

Excellent

Good

Fair

Poor

Would you recommend WholeCare Medical Staffing to another facility?

Yes

No

Comments