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:*   
Date of Service:*  (mm/dd/yyyy format)
Delivery and Instruction Tech Name:*
Unknown

 Access, Delivery and ServiceYesNoN/A
1Equipment/supplies were delivered in a timely manner.
2Equipment/supplies were ready for patient use upon delivery.
3Received and understood instructions on proper application and use of equipment/supplies.
4Feel confident to operate/use equipment/supplies.
5Received info on my Rights & Responsibilities, complaint process, billing, contact numbers.
6Response to my questions, problems, concerns were addressed in a timely manner.
7Satisfied with the equipment or supplies.
8Satisfied 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.


The Compliance Team
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