Patient Satisfaction Survey

Thank you for allowing us to provide you Pharmacy services. Please take a few minutes to give us your feedback on your experience. We value your comments and welcome any suggestions you may have to improve our services.

MARKING INSTRUCTIONS:
Please choose the most appropriate option for each question below.
Please explain any less than satisfied response(s) in the comment section below.

Question Title

* 2. Please tell us about yourself (optional)

Name:

Address:

Address 2

City/Town:

State/Province:

ZIP/Postal Code:

Phone Number:

	Very Satisfied	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied	N/A
Overall satisfaction with Rosemont Specialty Pharmacy	Overall satisfaction with Rosemont Specialty Pharmacy Very Satisfied	Overall satisfaction with Rosemont Specialty Pharmacy Satisfied	Overall satisfaction with Rosemont Specialty Pharmacy Somewhat Satisfied	Overall satisfaction with Rosemont Specialty Pharmacy Neutral	Overall satisfaction with Rosemont Specialty Pharmacy Somewhat Dissatisfied	Overall satisfaction with Rosemont Specialty Pharmacy Dissatisfied	Overall satisfaction with Rosemont Specialty Pharmacy N/A
Meeting your service expectations	Meeting your service expectations Very Satisfied	Meeting your service expectations Satisfied	Meeting your service expectations Somewhat Satisfied	Meeting your service expectations Neutral	Meeting your service expectations Somewhat Dissatisfied	Meeting your service expectations Dissatisfied	Meeting your service expectations N/A
Timeliness of the delivery of your medication	Timeliness of the delivery of your medication Very Satisfied	Timeliness of the delivery of your medication Satisfied	Timeliness of the delivery of your medication Somewhat Satisfied	Timeliness of the delivery of your medication Neutral	Timeliness of the delivery of your medication Somewhat Dissatisfied	Timeliness of the delivery of your medication Dissatisfied	Timeliness of the delivery of your medication N/A
Accuracy of your order	Accuracy of your order Very Satisfied	Accuracy of your order Satisfied	Accuracy of your order Somewhat Satisfied	Accuracy of your order Neutral	Accuracy of your order Somewhat Dissatisfied	Accuracy of your order Dissatisfied	Accuracy of your order N/A
Helpfulness of the information you receive about your medication	Helpfulness of the information you receive about your medication Very Satisfied	Helpfulness of the information you receive about your medication Satisfied	Helpfulness of the information you receive about your medication Somewhat Satisfied	Helpfulness of the information you receive about your medication Neutral	Helpfulness of the information you receive about your medication Somewhat Dissatisfied	Helpfulness of the information you receive about your medication Dissatisfied	Helpfulness of the information you receive about your medication N/A
Ability to reach a person by phone who could answer your questions	Ability to reach a person by phone who could answer your questions Very Satisfied	Ability to reach a person by phone who could answer your questions Satisfied	Ability to reach a person by phone who could answer your questions Somewhat Satisfied	Ability to reach a person by phone who could answer your questions Neutral	Ability to reach a person by phone who could answer your questions Somewhat Dissatisfied	Ability to reach a person by phone who could answer your questions Dissatisfied	Ability to reach a person by phone who could answer your questions N/A
Explanation of what you personally will pay after your insurance pays	Explanation of what you personally will pay after your insurance pays Very Satisfied	Explanation of what you personally will pay after your insurance pays Satisfied	Explanation of what you personally will pay after your insurance pays Somewhat Satisfied	Explanation of what you personally will pay after your insurance pays Neutral	Explanation of what you personally will pay after your insurance pays Somewhat Dissatisfied	Explanation of what you personally will pay after your insurance pays Dissatisfied	Explanation of what you personally will pay after your insurance pays N/A
Explanation of your insurance benefits	Explanation of your insurance benefits Very Satisfied	Explanation of your insurance benefits Satisfied	Explanation of your insurance benefits Somewhat Satisfied	Explanation of your insurance benefits Neutral	Explanation of your insurance benefits Somewhat Dissatisfied	Explanation of your insurance benefits Dissatisfied	Explanation of your insurance benefits N/A
Explanation on how you can refill your medication	Explanation on how you can refill your medication Very Satisfied	Explanation on how you can refill your medication Satisfied	Explanation on how you can refill your medication Somewhat Satisfied	Explanation on how you can refill your medication Neutral	Explanation on how you can refill your medication Somewhat Dissatisfied	Explanation on how you can refill your medication Dissatisfied	Explanation on how you can refill your medication N/A
Explanation of whom to call if there is an issue with your order	Explanation of whom to call if there is an issue with your order Very Satisfied	Explanation of whom to call if there is an issue with your order Satisfied	Explanation of whom to call if there is an issue with your order Somewhat Satisfied	Explanation of whom to call if there is an issue with your order Neutral	Explanation of whom to call if there is an issue with your order Somewhat Dissatisfied	Explanation of whom to call if there is an issue with your order Dissatisfied	Explanation of whom to call if there is an issue with your order N/A
Condition of medication when filled/received	Condition of medication when filled/received Very Satisfied	Condition of medication when filled/received Satisfied	Condition of medication when filled/received Somewhat Satisfied	Condition of medication when filled/received Neutral	Condition of medication when filled/received Somewhat Dissatisfied	Condition of medication when filled/received Dissatisfied	Condition of medication when filled/received N/A
Staff knowledge of health condition	Staff knowledge of health condition Very Satisfied	Staff knowledge of health condition Satisfied	Staff knowledge of health condition Somewhat Satisfied	Staff knowledge of health condition Neutral	Staff knowledge of health condition Somewhat Dissatisfied	Staff knowledge of health condition Dissatisfied	Staff knowledge of health condition N/A

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Overall satisfaction with Rosemont Specialty Pharmacy

Overall satisfaction with Rosemont Specialty Pharmacy Very Satisfied

Overall satisfaction with Rosemont Specialty Pharmacy Satisfied

Overall satisfaction with Rosemont Specialty Pharmacy Somewhat Satisfied

Overall satisfaction with Rosemont Specialty Pharmacy Neutral

Overall satisfaction with Rosemont Specialty Pharmacy Somewhat Dissatisfied

Overall satisfaction with Rosemont Specialty Pharmacy Dissatisfied

Overall satisfaction with Rosemont Specialty Pharmacy N/A

Meeting your service expectations

Meeting your service expectations Very Satisfied

Meeting your service expectations Satisfied

Meeting your service expectations Somewhat Satisfied

Meeting your service expectations Neutral

Meeting your service expectations Somewhat Dissatisfied

Meeting your service expectations Dissatisfied

Meeting your service expectations N/A

Timeliness of the delivery of your medication

Timeliness of the delivery of your medication Very Satisfied

Timeliness of the delivery of your medication Satisfied

Timeliness of the delivery of your medication Somewhat Satisfied

Timeliness of the delivery of your medication Neutral

Timeliness of the delivery of your medication Somewhat Dissatisfied

Timeliness of the delivery of your medication Dissatisfied

Timeliness of the delivery of your medication N/A

Accuracy of your order

Accuracy of your order Very Satisfied

Accuracy of your order Satisfied

Accuracy of your order Somewhat Satisfied

Accuracy of your order Neutral

Accuracy of your order Somewhat Dissatisfied

Accuracy of your order Dissatisfied

Accuracy of your order N/A

Helpfulness of the information you receive about your medication

Helpfulness of the information you receive about your medication Very Satisfied

Helpfulness of the information you receive about your medication Satisfied

Helpfulness of the information you receive about your medication Somewhat Satisfied

Helpfulness of the information you receive about your medication Neutral

Helpfulness of the information you receive about your medication Somewhat Dissatisfied

Helpfulness of the information you receive about your medication Dissatisfied

Helpfulness of the information you receive about your medication N/A

Ability to reach a person by phone who could answer your questions

Ability to reach a person by phone who could answer your questions Very Satisfied

Ability to reach a person by phone who could answer your questions Satisfied

Ability to reach a person by phone who could answer your questions Somewhat Satisfied

Ability to reach a person by phone who could answer your questions Neutral

Ability to reach a person by phone who could answer your questions Somewhat Dissatisfied

Ability to reach a person by phone who could answer your questions Dissatisfied

Ability to reach a person by phone who could answer your questions N/A

Explanation of what you personally will pay after your insurance pays

Explanation of what you personally will pay after your insurance pays Very Satisfied

Explanation of what you personally will pay after your insurance pays Satisfied

Explanation of what you personally will pay after your insurance pays Somewhat Satisfied

Explanation of what you personally will pay after your insurance pays Neutral

Explanation of what you personally will pay after your insurance pays Somewhat Dissatisfied

Explanation of what you personally will pay after your insurance pays Dissatisfied

Explanation of what you personally will pay after your insurance pays N/A

Explanation of your insurance benefits

Explanation of your insurance benefits Very Satisfied

Explanation of your insurance benefits Satisfied

Explanation of your insurance benefits Somewhat Satisfied

Explanation of your insurance benefits Neutral

Explanation of your insurance benefits Somewhat Dissatisfied

Explanation of your insurance benefits Dissatisfied

Explanation of your insurance benefits N/A

Explanation on how you can refill your medication

Explanation on how you can refill your medication Very Satisfied

Explanation on how you can refill your medication Satisfied

Explanation on how you can refill your medication Somewhat Satisfied

Explanation on how you can refill your medication Neutral

Explanation on how you can refill your medication Somewhat Dissatisfied

Explanation on how you can refill your medication Dissatisfied

Explanation on how you can refill your medication N/A

Explanation of whom to call if there is an issue with your order

Explanation of whom to call if there is an issue with your order Very Satisfied

Explanation of whom to call if there is an issue with your order Satisfied

Explanation of whom to call if there is an issue with your order Somewhat Satisfied

Explanation of whom to call if there is an issue with your order Neutral

Explanation of whom to call if there is an issue with your order Somewhat Dissatisfied

Explanation of whom to call if there is an issue with your order Dissatisfied

Explanation of whom to call if there is an issue with your order N/A

Condition of medication when filled/received

Condition of medication when filled/received Very Satisfied

Condition of medication when filled/received Satisfied

Condition of medication when filled/received Somewhat Satisfied

Condition of medication when filled/received Neutral

Condition of medication when filled/received Somewhat Dissatisfied

Condition of medication when filled/received Dissatisfied

Condition of medication when filled/received N/A

Staff knowledge of health condition

Staff knowledge of health condition Very Satisfied

Staff knowledge of health condition Satisfied

Staff knowledge of health condition Somewhat Satisfied

Staff knowledge of health condition Neutral

Staff knowledge of health condition Somewhat Dissatisfied

Staff knowledge of health condition Dissatisfied

Staff knowledge of health condition N/A

Patient Satisfaction Survey

Question Title

* 1. Email Address:

Question Title

* 2. Please tell us about yourself (optional)

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* 3. How would you rate your level of satisfaction with the following?

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* 4. How can we improve our services?

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* 5. Comments: