The Compliance Team

Exemplary Provider Satisfaction Measure^© — Universal Survey

Requested By:	Edward Arabov at Healthy Corner Pharmcy
Your Name:	First: Last:
Your Phone #:
New or Existing Patient:	New Existing
Equipment Category:
Model 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.

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