Customer Satisfaction Survey

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. 2. The equipment and/or supplies were clean when received. 3. The equipment operates properly. 4. Adequate instructions were provided for safe use of the equipment. 5. Our staff was courteous and helpful. 6. Our response to your questions, problems, and concerns was timely. 7. Our business practices allow easy & understandable access to equipment, items, services, and information. 8. My financial responsibilities were appropriately explained. 9. Overall, the services I received were to my satisfaction. 10. The service(s) I received met my healthcare needs. Comments:

I would like to be contacted about this survey.
If checked, please fill out the information below.

Your First Name:
Your Last Name:
Name of customer served (if not yourself):
Date of Service:
Phone:
Email:

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