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Patient Satisfaction Survey

Thank you for taking our short survey - we value your input!

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* 1. Location Code (located on the survey postcard):

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* 2. Status:

Active Patient

Discharged (Completed all services and no longer an active patient)

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* 3. I was satisfied with the overall quality of the services provided.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Comments:

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* 4. I would recommend this pharmacy to my family and friends.

Strongly agree

Agree

Neither agree nor disagree

Disagree

Strongly disagree

Comments:

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* 5. The medications and supplies arrived before I needed them.

Always

Very Often

Sometimes

Rarely

Never

Comments:

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* 6. My deliveries contained the right medications and supplies.

Always

Very Often

Sometimes

Rarely

Never

Comments:

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* 7. I knew who to call if I needed help with my therapy.

Yes

Comments:

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* 8. The response I received to phone calls for help on weekends or during evening hours met my needs.

Always

Very Often

Sometimes

Rarely

Never

I did not need to call for help on weekends or during evening hours.

Comments:

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* 9. The nurse or pharmacist informed me of the possible side effects of the medication.

Yes

Comments:

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* 10. I understood the explanation of my financial responsibilities for the therapy.

Yes

Comments:

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* 11. Rate how often each staff were courteous.

	Always	Very Often	Sometimes	Rarely	Never	N/A
Delivery Staff	Delivery Staff Always	Delivery Staff Very Often	Delivery Staff Sometimes	Delivery Staff Rarely	Delivery Staff Never	Delivery Staff N/A
Billing Staff	Billing Staff Always	Billing Staff Very Often	Billing Staff Sometimes	Billing Staff Rarely	Billing Staff Never	Billing Staff N/A
Pharmacy Staff	Pharmacy Staff Always	Pharmacy Staff Very Often	Pharmacy Staff Sometimes	Pharmacy Staff Rarely	Pharmacy Staff Never	Pharmacy Staff N/A
Nursing Staff	Nursing Staff Always	Nursing Staff Very Often	Nursing Staff Sometimes	Nursing Staff Rarely	Nursing Staff Never	Nursing Staff N/A

Comments

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* 12. Rate how often each staff were helpful.

	Always	Very Often	Sometimes	Rarely	Never	N/A
Delivery Staff	Delivery Staff Always	Delivery Staff Very Often	Delivery Staff Sometimes	Delivery Staff Rarely	Delivery Staff Never	Delivery Staff N/A
Billing Staff	Billing Staff Always	Billing Staff Very Often	Billing Staff Sometimes	Billing Staff Rarely	Billing Staff Never	Billing Staff N/A
Pharmacy Staff	Pharmacy Staff Always	Pharmacy Staff Very Often	Pharmacy Staff Sometimes	Pharmacy Staff Rarely	Pharmacy Staff Never	Pharmacy Staff N/A
Nursing Staff	Nursing Staff Always	Nursing Staff Very Often	Nursing Staff Sometimes	Nursing Staff Rarely	Nursing Staff Never	Nursing Staff N/A

Comments

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* 13. I understood the instructions provided for:

	Yes	No	N/A
How to wash my hands	How to wash my hands Yes	How to wash my hands No	How to wash my hands N/A
How to give medication(s)	How to give medication(s) Yes	How to give medication(s) No	How to give medication(s) N/A
How to care for the IV catheter	How to care for the IV catheter Yes	How to care for the IV catheter No	How to care for the IV catheter N/A
How to store medication(s)	How to store medication(s) Yes	How to store medication(s) No	How to store medication(s) N/A
How to use the home infusion pump	How to use the home infusion pump Yes	How to use the home infusion pump No	How to use the home infusion pump N/A

Comments:

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* 14. The pump was clean when it was delivered.

Yes

I did not use a pump.

Comments:

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* 15. The pump worked properly.

Yes

I did not use a pump.

Comments:

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Question Title

* 1. Location Code (located on the survey postcard):

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* 2. Status:

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* 3. I was satisfied with the overall quality of the services provided.

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* 4. I would recommend this pharmacy to my family and friends.

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* 5. The medications and supplies arrived before I needed them.

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* 6. My deliveries contained the right medications and supplies.

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* 7. I knew who to call if I needed help with my therapy.

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* 8. The response I received to phone calls for help on weekends or during evening hours met my needs.

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* 9. The nurse or pharmacist informed me of the possible side effects of the medication.

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* 10. I understood the explanation of my financial responsibilities for the therapy.

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* 11. Rate how often each staff were courteous.

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* 12. Rate how often each staff were helpful.

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* 13. I understood the instructions provided for:

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* 14. The pump was clean when it was delivered.

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* 15. The pump worked properly.

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* 16. Comments: