The Compliance Team

Patient Satisfaction Survey — Universal

Items below designated with an asterisk ( *) are required.
Requested By:	Dat Nguyen at
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.
2	Equipment/supplies were ready for patient use upon delivery.
3	Received and understood instructions on proper application and use of equipment/supplies.
4	Feel confident to operate/use equipment/supplies.
5	Received info on my Rights & Responsibilities, complaint process, billing, contact numbers.
6	Response to my questions, problems, concerns were addressed in a timely manner.
7	Satisfied with the equipment or supplies.
8	Satisfied with the service. Would recommend to others.

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.