Integrity is our creed...
Phone: 763.566. 
                               Customer Satisfaction is our business!

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Customer Satisfaction Survey Form
  Use this form to let us know how we are doing. We value your opinion and look forward to helping you again.

Please read the following statements and indicate the quality of service.

5=Excellent 4=Good 3=Average 2=Fair 1=Poor

1. The equipment and/or supplies were delivered at the agreed upon time.
5 4 3 2 1

2. The equipment and/or supplies were clean when received.
5 4 3 2 1

3. The equipment operates properly.
5 4 3 2 1

4. Adequate instructions were provided for safe use of the equipment.
5 4 3 2 1

5. Our staff was courteous and helpful.
5 4 3 2 1

6. Our response to your questions, problems, and concerns was timely.
5 4 3 2 1

7. Our business practices allow easy & understandable access to equipment, items, services, and information.
5 4 3 2 1

8. My financial responsibilities were appropriately explained.
5 4 3 2 1

9. Overall, the services I received were to my satisfaction.
5 4 3 2 1

10. The service(s) I received met my healthcare needs.
5 4 3 2 1

Comments:

Check this box if you would like to be contacted about this survey:
If checked, please fill out the information below.

Your Name:

Name of customer served (if not yourself):

Date of service:
Email:
Phone #:

      

Security Notice: The information contained in this from will be transmitted across an unsecured connection to Reliable Medical Supply, Inc. By clicking the submit button you are agreeing to release all responsibilities or liabilities of Reliable Medical Supply for lost or stolen information contained in this form. Click here for more information on our email privacy.
You can also print this page and send it through conventional mail to:
Reliable Medical Supply, Inc.
Attn: Patient Services
7111 West Broadway Avenue
Brooklyn Park, MN 55428
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