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The Compliance Team
Exemplary Provider Satisfaction Measure© — Diabetic Survey
Requested By: Edward Arabov at Healthy Corner Pharmcy
Your Name:
First:      Last:
Your Phone #:
New or Existing Patient:   
Equipment Category:
Model or Serial # (as applicable):
Date Of Service:  (mm/dd/yyyy format)
Delivery and Instruction Tech Name:

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

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