To better serve you, we would like to know how you feel about the services you recently received by Northside Home Infusion. Please take a few minutes to complete this brief questionnaire.

* 1. Was our staff courteous and respectful to you and your property?

* 2. Were your questions and requests addressed appropriately and in a timely manner?

* 3. Were your medications, equipment and supplies available when you needed them?

* 4. Was your equipment clean and in good working condition?

* 5. Were there any safety issues that concerned you during therapy?

* 6. Were equipment problems resolved in a satisfactory manner?

* 7. Were you satisfied with our after-hours and weekend service?

* 8. Do you have our telephone number available for questions?

* 9. Overall were you satisfied with our services?

* 10. Will you recommend us to others?

* 11. (Optional) Name / Phone

* 12. Comments/Suggestions for improvement in safety and services: