How helpful did you find the Medicare Basics program? *

Very helpful

Somewhat helpful

Not very helpful

Not helpful at all

How likely are you to recommend this program to others? *

1 (not likely)

2

3

4

5

6

7

8

9

10 (very likely)

Would you recommend this program to others?

Yes, definitely.

Maybe.

No.

Would you like someone to contact you with additional information?

Yes, please! My contact information is below.

I've already made an appointment.

No, thanks.

Name

First Name

Last Name

Phone

(###)

###

####

Opt in to Senior PharmAssist emails (7-10/year)?

Sure!

No, thanks.