Tops Pharmacy Patient Satisfaction Survey Providing excellent customer service is a top priority for Tops Specialty Pharmacy. Thank you for taking the time to participate in this survey. Question Title * 1. Please rate your degree of satisfaction on a scale of 1 (completely dissatisfied) to 5 (completely satisfied) Completely Dissatisifed Somewhat Dissatisfied Neutral Somewhat Satisfied Completely Satisfied Customer service provided by the pharmacist Customer service provided by the pharmacist Completely Dissatisifed Customer service provided by the pharmacist Somewhat Dissatisfied Customer service provided by the pharmacist Neutral Customer service provided by the pharmacist Somewhat Satisfied Customer service provided by the pharmacist Completely Satisfied Customer service provided by the pharmacy associate Customer service provided by the pharmacy associate Completely Dissatisifed Customer service provided by the pharmacy associate Somewhat Dissatisfied Customer service provided by the pharmacy associate Neutral Customer service provided by the pharmacy associate Somewhat Satisfied Customer service provided by the pharmacy associate Completely Satisfied Product education/training provided Product education/training provided Completely Dissatisifed Product education/training provided Somewhat Dissatisfied Product education/training provided Neutral Product education/training provided Somewhat Satisfied Product education/training provided Completely Satisfied Quality of product/service received Quality of product/service received Completely Dissatisifed Quality of product/service received Somewhat Dissatisfied Quality of product/service received Neutral Quality of product/service received Somewhat Satisfied Quality of product/service received Completely Satisfied All questions/concerns were addressed All questions/concerns were addressed Completely Dissatisifed All questions/concerns were addressed Somewhat Dissatisfied All questions/concerns were addressed Neutral All questions/concerns were addressed Somewhat Satisfied All questions/concerns were addressed Completely Satisfied Question Title * 2. Overall I am satisfied with Tops Markets Specialty Pharmacy Agree Somewhat Agree Neutral Somewhat Disagree Completely Disagree Question Title * 3. Please Choose Yes or No to the following: Yes No N/A Your name and date of birth were confirmed by an associate at the pharmacy checkout Your name and date of birth were confirmed by an associate at the pharmacy checkout Yes Your name and date of birth were confirmed by an associate at the pharmacy checkout No Your name and date of birth were confirmed by an associate at the pharmacy checkout N/A An associate asked if you had any questions for the pharmacist or if you would like to be counseled on your prescription An associate asked if you had any questions for the pharmacist or if you would like to be counseled on your prescription Yes An associate asked if you had any questions for the pharmacist or if you would like to be counseled on your prescription No An associate asked if you had any questions for the pharmacist or if you would like to be counseled on your prescription N/A An associate reviewed your co-payments and final charges with you to make sure they were correct at the pharmacy checkout An associate reviewed your co-payments and final charges with you to make sure they were correct at the pharmacy checkout Yes An associate reviewed your co-payments and final charges with you to make sure they were correct at the pharmacy checkout No An associate reviewed your co-payments and final charges with you to make sure they were correct at the pharmacy checkout N/A You were provided an attestation form to sign, where applicable You were provided an attestation form to sign, where applicable Yes You were provided an attestation form to sign, where applicable No You were provided an attestation form to sign, where applicable N/A Question Title * 4. Please add any comments about your Tops Markets Specialty Program experience. Question Title * 5. Enter Date of Service Date / Time Date Question Title * 6. Please enter the store number or the city of the Tops Markets Pharmacy you visited. The store number is the 3 digit number after the prescription number on your pharmacy receipt or prescription label. (ex. Rx# 1234567- 112). Question Title * 7. What pharmacy service were you provided? Please select all that apply Prescription Filling Vaccination (for example: flu, pneumonia, shingles) Counseling on medications or over-the-counter products Other (please specify) Question Title * 8. May we contact you? Yes No Contact information Done
