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Customer Service Survey

Name
 
 
Birth Day
 
Product Ordered 
 


Please rate on the following scale:

(1) Very Dissatisfied (2) (3) (4) (5) Very Satisfied  
             
The staff explained to you what to expect during home care of pharmacy service.  
             
The staff allowed you to participate in decisions that affect the care.  
             
The staff explained financial responsibility, insurance coverage, and cost (if any).  
             
The staff explained your right to have personal health information kept private.  
             
The staff helped you if you complained about problems with the service.  
             
The staff explained your rights and responsibilities  
             
The staff explained how to voice a complaint.  
             
The equipment, medications, and/or supplies were delivered on time.  
             
The equipment was clean when it was delivered.  
             
The equipment remained in good working order.  
             
The instructions were adequate for safe use of the equipment and/or merchandise.  
             
The staff was respectful and courteous in your home.  
             
You were satisfied with the office staff (reception, billing, etc.).  
You were satisfied with the timeliness of response to your billing or payment questions, problems and documents.  
             
The staff was easy to reach if you called for assistance on weekends and during evening hours.  
             
You were told who to call if the equipment stopped working properly or if there was an adverse medication event.  
             
You were told what to do if the services were interrupted due to the weather or a natural disaster.  
             
The services provided met your needs and expectations.  
             
You were satisfied with the overall quality of care and services. *  
             
You would likely recommend the services to your family and friends. *  
             

Suggestions on how we can improve: