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.

Was our staff courteous and respectful to you and your property?

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

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

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

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

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

Was your equipment clean and in good working condition?

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

Were there any safety issues that concerned you during therapy?

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

Were equipment problems resolved in a satisfactory manner?

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

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

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

Do you have our telephone number available for questions?

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

Overall were you satisfied with our services?

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* 9. Overall were you satisfied with our services?

Will you recommend us to others?

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* 10. Will you recommend us to others?

(Optional) Name / Phone

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* 11. (Optional) Name / Phone

Comments/Suggestions for improvement in safety and services:

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

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