Patient Satisfaction Survey | Pharmacy

This survey is to assess the patient experience at HOPES and to help us improve our service delivery.

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* 1. Patient age:

0 - 2

3 - 10

11 - 15

16 – 19

20 – 29

30 – 45

46 – 65

65 or above

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* 2. My racial ethnic background is

African-American

Hispanic/Latino

Asian Pacific Islander

Native American/Alaskan

White

Other (please specify)

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* 3. My sexual orientation is

Heterosexual

Lesbian/Gay

Bisexual

Prefer not to answer

Other (please specify)

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* 4. My sex or gender is

Female

Male

Transgender (M to F)

Transgender (F to M)

Other (please specify)

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* 5. The services I have used at HOPES include (Check all that are applicable)

Adult Primary Care

Pediatrics

Medication Assisted Treatment (MAT)

Wound Care

Behavioral Health

Radiology

Case Management

HIV

Hepatitis C

Pharmacy

Psychiatry

Transportation

Insurance Enrollment

Billing

Transgender

Other (please specify)

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* 6. Please evaluate the following statements.

	Strongly Agree	Agree	Disagree	Strongly Disgree	Does Not Apply
The Pharmacy hours are convenient and work with my schedule	The Pharmacy hours are convenient and work with my schedule Strongly Agree	The Pharmacy hours are convenient and work with my schedule Agree	The Pharmacy hours are convenient and work with my schedule Disagree	The Pharmacy hours are convenient and work with my schedule Strongly Disgree	The Pharmacy hours are convenient and work with my schedule Does Not Apply
The pharmacy staff are friendly and courteous during my medication refill/pickup.	The pharmacy staff are friendly and courteous during my medication refill/pickup. Strongly Agree	The pharmacy staff are friendly and courteous during my medication refill/pickup. Agree	The pharmacy staff are friendly and courteous during my medication refill/pickup. Disagree	The pharmacy staff are friendly and courteous during my medication refill/pickup. Strongly Disgree	The pharmacy staff are friendly and courteous during my medication refill/pickup. Does Not Apply
The Pharmacy provides my medication in a timely manner.	The Pharmacy provides my medication in a timely manner. Strongly Agree	The Pharmacy provides my medication in a timely manner. Agree	The Pharmacy provides my medication in a timely manner. Disagree	The Pharmacy provides my medication in a timely manner. Strongly Disgree	The Pharmacy provides my medication in a timely manner. Does Not Apply
I am able to communicate with the pharmacy about my medication when needed.	I am able to communicate with the pharmacy about my medication when needed. Strongly Agree	I am able to communicate with the pharmacy about my medication when needed. Agree	I am able to communicate with the pharmacy about my medication when needed. Disagree	I am able to communicate with the pharmacy about my medication when needed. Strongly Disgree	I am able to communicate with the pharmacy about my medication when needed. Does Not Apply

Patient Satisfaction Survey | Pharmacy

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* 1. Patient age:

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* 2. My racial ethnic background is

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* 3. My sexual orientation is

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* 4. My sex or gender is

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* 5. The services I have used at HOPES include (Check all that are applicable)

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* 6. Please evaluate the following statements.

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* 7. What other services would you like to see at HOPES in the next couple of years?

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* 8. Thank you for helping with this survey. Please feel free to write additional comments/compliments here.