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Customer Satisfaction Survey
Circle your choices: 5 = Excellent; 4 = Good; 3 = Average; 2 = Fair; 1 = Poor;
| 1. The equipment and/or supplies were delivered at the agreed upon time. |
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| 2. The equipment and/or supplies were clean when received. |
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| 3. The equipment operates properly. |
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| 4. Adequate instructions were provided for the safe use of the equipment. |
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| 5. Our staff was courteous and helpful. |
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| 6. Our response to your questions, problems and concerns was timely. |
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| 7. Our business practices allow easy & understandable access to equipment, items, services and information. |
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| 8. Our staff provided you with a packet which included information about Pt. rights, responsibilities and privacy. |
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| 9. Staff gives brief explanation of what my insurance covers, and what my financial responsibilities will be. |
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| 10. If applicable, how would you rate Medicare's rules regarding HME and how these rules affect access to products and services with the provider I choose? |
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| 11. What can we do to improve our service? | |
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| 12. What products do we not currently carry that you would like to see offered? | |
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| Name * | |
| Email Address * | |
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| Comments / Complaints: * | |
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