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Patient Satisfaction Survey — Diabetic
Items below designated with an asterisk (
*
) are required.
Requested By:
Your Name:
First:
Last:
Your Phone #:
Use the following format (XXX) XXX-XXXX
New or Existing Patient:
*
New
Existing
Equipment:
*
Make or Serial # (as applicable):
Date of Service:
*
(mm/dd/yyyy format)
Delivery and Instruction Tech Name:
Unknown
Access, Delivery and Service
Yes
No
N/A
1
Equipment/supplies were delivered in a timely manner.
Reason:
Update Reason
2
Received and understood instructions on proper application and use of equipment/supplies.
Reason:
Update Reason
3
Customer is able to test successfully.
Reason:
Update Reason
4
Feel confident to operate/use equipment/supplies.
Reason:
Update Reason
5
Received info on my Rights & Responsibilities, complaint process, billing, contact numbers, and reasons.
Reason:
Update Reason
6
Response to my questions, problems, concerns were addressed in a timely manner.
Reason:
Update Reason
7
Satisfied with the equipment or supplies.
Reason:
Update Reason
8
Satisfied with the service.
Reason:
Update Reason
COMMENTS:
We greatly appreciate your input. We use patient satisfaction survey reports to help us improve our day-to-day services. Please take an extra minute to provide details for your survey responses in the box below.
Question:
You answered, "No" for the question shown above. Using the text box below, please provide the details as to why you answered, "No".
Please provide your details in the text box above and then click the "Save" button below.
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