Dear Patient, It is our desire to provide you with the best quality services available. In order to help us maintain our high standards, please take a few moments to tell us how we are doing. Please complete this form. Thank you.

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1. Were your medications delivered on time?

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2. Were the medications dispensed and delivered accurately?

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3. Was the pharmacy training provided effective in educating you on your therapy?

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4. Were the educational materials and instructions provided to you adequate to educate you on the medications dispensed to you?

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5. Was the pharmacy staff courteous and helpful?

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6. Were your financial responsibilities explained to you?

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7. Do you receive advice or help from the pharmacy when needed?

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8. Did the services provided make a positive impact on the outcome of your care and/or therapy?

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9. Would you recommend our pharmacy to your friends and family?

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10. Did the services provided meet your needs and expectations?

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11. First and Last Name

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12. Date:

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