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Satisfaction Survey
Satisfaction Survey
Your feedback matters. Tell us how we are doing.
Satisfaction Survey
Date
*
MM slash DD slash YYYY
Name
First
Last
Phone
*
Email
*
Items were delivered in a timely manner.
*
Yes
No
N/A
Items were ready for patient use upon delivery.
*
Yes
No
N/A
Received and understood instructions on proper use of items.
*
Yes
No
N/A
Feel confident to use items.
*
Yes
No
N/A
Received info on my Rights & Responsibilities (Consent and Authorization Form).
*
Yes
No
N/A
Response to my questions, problems, concerns were addressed in a timely manner.
*
Yes
No
N/A
Satisfied with the items.
*
Yes
No
N/A
Satisfied with the service. Would recommend to others.
*
Yes
No
N/A
Comments
Email
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