Customer Satisfaction Survey

How Are We Doing?

We are committed to providing the highest quality and service possible. Please help us by completing this survey. Be assured that your responses will be used solely to improve our services and ensure that we meet your expectations. We appreciate your comments and the opportunity to serve you.

1. Which of our branches provided service?

Which of our branches provided service?

2. Please rate your degree of satisfaction by checking the box that best reflects your opinion for each of the following questions/statements.

	Excellent	Good	Average	Fair	Poor	Not Applicable
The equipment and/or supplies were delivered at the agreed upon time.	*Please rate your degree of satisfaction by checking the box that best reflects your opinion for each of the following questions/statements. The equipment and/or supplies were delivered at the agreed upon time. Excellent	The equipment and/or supplies were delivered at the agreed upon time. Good	The equipment and/or supplies were delivered at the agreed upon time. Average	The equipment and/or supplies were delivered at the agreed upon time. Fair	The equipment and/or supplies were delivered at the agreed upon time. Poor	The equipment and/or supplies were delivered at the agreed upon time. Not Applicable
The equipment and/or supplies were clean when received.	The equipment and/or supplies were clean when received. Excellent	The equipment and/or supplies were clean when received. Good	The equipment and/or supplies were clean when received. Average	The equipment and/or supplies were clean when received. Fair	The equipment and/or supplies were clean when received. Poor	The equipment and/or supplies were clean when received. Not Applicable
The equipment operates properly.	The equipment operates properly. Excellent	The equipment operates properly. Good	The equipment operates properly. Average	The equipment operates properly. Fair	The equipment operates properly. Poor	The equipment operates properly. Not Applicable
Adequate instructions were provided for the safe use of the equipment.	Adequate instructions were provided for the safe use of the equipment. Excellent	Adequate instructions were provided for the safe use of the equipment. Good	Adequate instructions were provided for the safe use of the equipment. Average	Adequate instructions were provided for the safe use of the equipment. Fair	Adequate instructions were provided for the safe use of the equipment. Poor	Adequate instructions were provided for the safe use of the equipment. Not Applicable
That staff was courteous and helpful.	That staff was courteous and helpful. Excellent	That staff was courteous and helpful. Good	That staff was courteous and helpful. Average	That staff was courteous and helpful. Fair	That staff was courteous and helpful. Poor	That staff was courteous and helpful. Not Applicable
Our response to your questions, problems and concerns was timely.	Our response to your questions, problems and concerns was timely. Excellent	Our response to your questions, problems and concerns was timely. Good	Our response to your questions, problems and concerns was timely. Average	Our response to your questions, problems and concerns was timely. Fair	Our response to your questions, problems and concerns was timely. Poor	Our response to your questions, problems and concerns was timely. Not Applicable
Our business practices allow easy and understandable access to equipment, items, services, and information.	Our business practices allow easy and understandable access to equipment, items, services, and information. Excellent	Our business practices allow easy and understandable access to equipment, items, services, and information. Good	Our business practices allow easy and understandable access to equipment, items, services, and information. Average	Our business practices allow easy and understandable access to equipment, items, services, and information. Fair	Our business practices allow easy and understandable access to equipment, items, services, and information. Poor	Our business practices allow easy and understandable access to equipment, items, services, and information. Not Applicable
My financial responsibility was explained.	My financial responsibility was explained. Excellent	My financial responsibility was explained. Good	My financial responsibility was explained. Average	My financial responsibility was explained. Fair	My financial responsibility was explained. Poor	My financial responsibility was explained. Not Applicable
The after-hours/on-call policy was explained.	The after-hours/on-call policy was explained. Excellent	The after-hours/on-call policy was explained. Good	The after-hours/on-call policy was explained. Average	The after-hours/on-call policy was explained. Fair	The after-hours/on-call policy was explained. Poor	The after-hours/on-call policy was explained. Not Applicable
Overall, the services I received were to my satsifaction.	Overall, the services I received were to my satsifaction. Excellent	Overall, the services I received were to my satsifaction. Good	Overall, the services I received were to my satsifaction. Average	Overall, the services I received were to my satsifaction. Fair	Overall, the services I received were to my satsifaction. Poor	Overall, the services I received were to my satsifaction. Not Applicable

3. What equipment and/or supplies did we provide to you?

What equipment and/or supplies did we provide to you?

4. We appreciate any comments or suggestions on how we could improve safety:

We appreciate any comments or suggestions on how we could improve safety:

5. We appreciate any other comments or suggestions:

We appreciate any other comments or suggestions:

6. Optional information:

Optional information: Patient name:
Phone:
Physician name:
Referral name:
Roberts' staff member name:

Thank you for completing our patient/client satisfaction survey.

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