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Patient Satisfaction Survey — Universal
Requested By:
Edward Arabov 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:
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
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