Progenix Patient Survey

Your thoughts are very important to us, and we value your feedback. If you have any questions or need further assistance, please call our corporate office at 703.383.0889.

1. Contact Information

Contact Information Name:
Address:
City/Town:
State:
ZIP/Postal Code:
Device Serial Number:
Email Address:
Phone Number:

2. Please rate each section as it pertains to you.

	Excellent	Good	Average	Fair	Poor	N/A
Was the equipment and/or supplies delivered at the agreed upon time?	*Please rate each section as it pertains to you. Was the equipment and/or supplies delivered at the agreed upon time? Excellent	Was the equipment and/or supplies delivered at the agreed upon time? Good	Was the equipment and/or supplies delivered at the agreed upon time? Average	Was the equipment and/or supplies delivered at the agreed upon time? Fair	Was the equipment and/or supplies delivered at the agreed upon time? Poor	Was the equipment and/or supplies delivered at the agreed upon time? N/A
Was the equipment and/or supplies clean when received?	Was the equipment and/or supplies clean when received? Excellent	Was the equipment and/or supplies clean when received? Good	Was the equipment and/or supplies clean when received? Average	Was the equipment and/or supplies clean when received? Fair	Was the equipment and/or supplies clean when received? Poor	Was the equipment and/or supplies clean when received? N/A
Does the equipment operate properly?	Does the equipment operate properly? Excellent	Does the equipment operate properly? Good	Does the equipment operate properly? Average	Does the equipment operate properly? Fair	Does the equipment operate properly? Poor	Does the equipment operate properly? N/A
Were adequate instructions provided for the safe use of the equipment?	Were adequate instructions provided for the safe use of the equipment? Excellent	Were adequate instructions provided for the safe use of the equipment? Good	Were adequate instructions provided for the safe use of the equipment? Average	Were adequate instructions provided for the safe use of the equipment? Fair	Were adequate instructions provided for the safe use of the equipment? Poor	Were adequate instructions provided for the safe use of the equipment? N/A
Was the staff courteous and helpful?	Was the staff courteous and helpful? Excellent	Was the staff courteous and helpful? Good	Was the staff courteous and helpful? Average	Was the staff courteous and helpful? Fair	Was the staff courteous and helpful? Poor	Was the staff courteous and helpful? N/A

3. Were your financial obligations properly explained to you?

Were your financial obligations properly explained to you? Yes

4. Would you recommend our service to your friends and family?

Would you recommend our service to your friends and family? Yes

5. Please provide us any additional feedback or suggestions you might have that would help us provide you a better patient experience.