Dear Patient, It is our desire to provide you with the best quality services available. In order to help us maintain our high standards, please take a few moments to tell us how we are doing. Please complete this form. Thank you.

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* 1. Were your medications delivered on time?

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* 2. Were the medications dispensed and delivered accurately?

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* 3. Was the pharmacy training provided effective in educating you on your therapy?

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* 4. Were the educational materials and instructions provided to you adequate to educate you on the medications dispensed to you?

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* 5. Was the pharmacy staff courteous and helpful?

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* 6. Were your financial responsibilities explained to you?

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* 7. Do you receive advice or help from the pharmacy when needed?

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* 8. Did the services provided make a positive impact on the outcome of your care and/or therapy?

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* 9. Would you recommend our pharmacy to your friends and family?

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* 10. Did the services provided meet your needs and expectations?

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* 11. First and Last Name

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* 12. Date:

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