NELC Patient Satisfaction Survey

Question Title

* 1. Please rate how often NELC staff were helpful and courteous.

Always

Very Often

Sometimes

Rarely

Never

Comments:

Question Title

* 2. 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 the home infusion medication(s)	How to give the home infusion medication(s) Yes	How to give the home infusion medication(s) No	How to give the home infusion 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 the home infusion medication(s)	How to store the home infusion medication(s) Yes	How to store the home infusion medication(s) No	How to store the home infusion 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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* 3. I was satisfied with the overall quality of the services provided.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Comments:

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* 4. I would recommend New England Life Care to my family and friends.

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Comments:

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* 5. I understood the explanation of my financial responsibilities for home infusion/enteral therapy.

Yes

No

Comments:

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* 6. Providing the following information is optional

Name

Email Address

Phone Number

Insurance Provider

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* 7. Would you like someone to contact you regarding your response to this survey?

Yes

No

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* 8. Are you willing to answer a few more questions?

Yes

No