Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Question Title * Contact Information Patient Name Phone Number Date Patient Received Equipment Alt. Contact Person Relationship to Patient Alternative Contact Phone Number OK Question Title * Type of Equipment Received. CPAP/BiPAP Diabetic Shoes Other OK Question Title * Equipment/Supplies was delivered in a timely manner. Yes No NA OK Question Title * Equipment/Supplies was ready for patient use upon delivery. Yes No NA OK Question Title * Received and understood instructions on the proper application and use of equipment/supplies. Yes No NA OK Question Title * Feel confident to operate/use equipment/supplies. Yes No NA OK Question Title * Received info on my Rights & Responsibilities, complaint process, billing, contact numbers, and reasons to notify the equipment/supply company. Yes No NA OK Question Title * Satisfaction with equipment or supplies. Yes No NA OK Question Title * Satisfied with the service. Yes No NA OK Question Title * Would recommend service to others. Yes No NA OK NEXT