Medical Patient Survey
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1. Fairview Home Medical Equipment Sleep Therapy Survey
1
. Name the location where you received your equipment and supplies.
Name the location where you received your equipment and supplies.
Fairview Home Medical Equipment Burnsville
Fairview Home Medical Equipment St. Paul
Fairview Lakes Chisago Sleep Center
Fairview Red Wing Sleep Center
Fairview Southdale Sleep Center
UMMC Fairview Riverside Sleep Center
2
. Clinician Name
Clinician Name
3
. Patient's Gender
Patient's Gender
Female
Male
4
. Were you greeted in a timely and courteous manner?
Were you greeted in a timely and courteous manner?
Strongly Agree
Agree
Disagree
Strongly Disagree
5
. You received the information necessary to understand your sleep disorder?
You received the information necessary to understand your sleep disorder?
Strongly Agree
Agree
Disagree
Strongly Disagree
6
. You understand the benefits of regular nightly use of your PAP therapy?
You understand the benefits of regular nightly use of your PAP therapy?
Strongly Agree
Agree
Disagree
Strongly Disagree
7
. Were you satisfied with the variety of products?
Were you satisfied with the variety of products?
Strongly Agree
Agree
Disagree
Strongly Disagree
8
. Staff responded appropriately to your concerns and answered your questions?
Staff responded appropriately to your concerns and answered your questions?
Strongly Agree
Agree
Disagree
Strongly Disagree
9
. Will you continue to use Fairview Home Medical Equipment for service and products?
Will you continue to use Fairview Home Medical Equipment for service and products?
Strongly Agree
Agree
Disagree
Strongly Disagree
10
. Likelihood of recommending our service to others?
Likelihood of recommending our service to others?
Strongly Agree
Agree
Disagree
Strongly Disagree
11
. Please include any additional thoughts you have about your experience in the space provided below.
Please include any additional thoughts you have about your experience in the space provided below.
12
. If you would like to be contacted personally about your experience, include your name and contact information below.
If you would like to be contacted personally about your experience, include your name and contact information below.
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