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# Feedback Form

Better Health Feedback Form

- # Better Health Feedback Form

At Better Health we strive to provide the best experience to our members. In an effort to improve our services, we’d appreciate it if you could take a few minutes to tell us about your experience with Better Health.

- Name\*

First NameLast Name

- Phone Number\*
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- Email\*
If no email, use firstname.lastname@noemail.com

- Would you like to continue receiving supplies from Better Health?\*

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- Please indicate why you are cancelling all future orders from Better Health.\*

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- How could we have improved your experience with Better Health?\*

- On a scale of 0 to 10, how likely are you to recommend Better Health to a friend or colleague?\*
Please Select10 - Extremely likely9876543210 - Not at all likely

- Additional comments:

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**Use left/right arrows to navigate the slideshow or swipe left/right if using a mobile device**

**- Choosing a selection results in a full page refresh.**
**- Press the space key then arrow keys to make a selection.**

**\**\
**Am I eligible?\**\
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**Takes a few minutes.](/content/pages/vr-for-pain-management/index.html) \**\
**Is this covered by insurance?\**\
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**Check my coverage](/content/pages/feedback-form#/index.html)**

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**Have questions?\**\
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**## We are asking you a few questions to   determine if Better Health can help you    meet your needs.**

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**Select all that apply. This helps us bill your insurance so you don’t pay out of pocket.**

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****Better Health** Membership Benefits**

**- Free & Fast 2-day shipping.**
**- Personal care team**
**- Easy re-orders via SMS**
**- Access to free samples**
**- Widest product selection**

**### Need Help? Call our Care specialist.**

**We're available from**

**Monday to Friday**

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**[415-475-8444](tel: 415-475-8444)**

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**Product of interest**

**What insurance(s) do you have?**

**Medicare**

**Medicaid**

**Medicare Advantage**

**Private or Employer Provided**

**I agree to be contacted by Better Health**

**I authorize Better Health Supplies, Inc. to contact me by phone, email and sms. View our [privacy policy](/content/pages/privacy-policy/index.html). I have read and agree to these [terms and conditions](/content/pages/terms-and-conditions/index.html).**

**Submit**

****

****

****Better Health** Membership Benefits**

**- Free & Fast 2-day shipping.**
**- Personal care team**
**- Easy re-orders via SMS**
**- Access to free samples**
**- Widest product selection**

**### Need Help? Call our Care specialist.**

**We're available from**

**Monday to Friday**

**8:30am ~ 8:30pm EST**

**[415-475-8444](tel: 415-475-8444)**

**Cart(0)Questions?**

**## Get a free price quote**

**United States**

**First name**

**Last name**

**Email**

**Phone number**

**Product of interest**

**What insurance(s) do you have?**

**Medicare**

**Medicaid**

**Medicare Advantage**

**Private**

**I agree to be contacted by Better Health**

**Submit**

**## How can Better Health help you today?**

**Want to order more of my current product.Want personalized help finding the right product.Want to browse products.Want to request free samples.**

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**Continue**

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