Patient Satisfaction Survey

Dear Customer,

Recently you received products from Elite Home Medical & Respiratory, Inc. Your opinion is very important to us. We use your feedback to improve our services and provide the best care.

Please take a few moments to complete this questionnaire. Your results will be electronically submitted to us. Thank you from The Elite Home Medical & Respiratory, Inc. Team.

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Was the equipment delivered in a timely manner?	Was the equipment delivered in a timely manner? 0	Was the equipment delivered in a timely manner? 1	Was the equipment delivered in a timely manner? 2	Was the equipment delivered in a timely manner? 3	Was the equipment delivered in a timely manner? 4	Was the equipment delivered in a timely manner? 5
Was the equipment in good operating condition?	Was the equipment in good operating condition? 0	Was the equipment in good operating condition? 1	Was the equipment in good operating condition? 2	Was the equipment in good operating condition? 3	Was the equipment in good operating condition? 4	Was the equipment in good operating condition? 5
Was the product supplied clean?	Was the product supplied clean? 0	Was the product supplied clean? 1	Was the product supplied clean? 2	Was the product supplied clean? 3	Was the product supplied clean? 4	Was the product supplied clean? 5

Was the equipment delivered in a timely manner?

Was the equipment delivered in a timely manner? 0

Was the equipment delivered in a timely manner? 1

Was the equipment delivered in a timely manner? 2

Was the equipment delivered in a timely manner? 3

Was the equipment delivered in a timely manner? 4

Was the equipment delivered in a timely manner? 5

Was the equipment in good operating condition?

Was the equipment in good operating condition? 0

Was the equipment in good operating condition? 1

Was the equipment in good operating condition? 2

Was the equipment in good operating condition? 3

Was the equipment in good operating condition? 4

Was the equipment in good operating condition? 5

Was the product supplied clean?

Was the product supplied clean? 0

Was the product supplied clean? 1

Was the product supplied clean? 2

Was the product supplied clean? 3

Was the product supplied clean? 4

Was the product supplied clean? 5

	0	1	2	3	4	5
Was the delivery person courteous and professional?	Was the delivery person courteous and professional? 0	Was the delivery person courteous and professional? 1	Was the delivery person courteous and professional? 2	Was the delivery person courteous and professional? 3	Was the delivery person courteous and professional? 4	Was the delivery person courteous and professional? 5
Did our staff provide clear operating instructions?	Did our staff provide clear operating instructions? 0	Did our staff provide clear operating instructions? 1	Did our staff provide clear operating instructions? 2	Did our staff provide clear operating instructions? 3	Did our staff provide clear operating instructions? 4	Did our staff provide clear operating instructions? 5
Did our staff satisfactorily address your questions?	Did our staff satisfactorily address your questions? 0	Did our staff satisfactorily address your questions? 1	Did our staff satisfactorily address your questions? 2	Did our staff satisfactorily address your questions? 3	Did our staff satisfactorily address your questions? 4	Did our staff satisfactorily address your questions? 5
Did our staff explain insurance & financial responsibility?	Did our staff explain insurance & financial responsibility? 0	Did our staff explain insurance & financial responsibility? 1	Did our staff explain insurance & financial responsibility? 2	Did our staff explain insurance & financial responsibility? 3	Did our staff explain insurance & financial responsibility? 4	Did our staff explain insurance & financial responsibility? 5
Was safety and emergency information presented?	Was safety and emergency information presented? 0	Was safety and emergency information presented? 1	Was safety and emergency information presented? 2	Was safety and emergency information presented? 3	Was safety and emergency information presented? 4	Was safety and emergency information presented? 5

Was the delivery person courteous and professional?

Was the delivery person courteous and professional? 0

Was the delivery person courteous and professional? 1

Was the delivery person courteous and professional? 2

Was the delivery person courteous and professional? 3

Was the delivery person courteous and professional? 4

Was the delivery person courteous and professional? 5

Did our staff provide clear operating instructions?

Did our staff provide clear operating instructions? 0

Did our staff provide clear operating instructions? 1

Did our staff provide clear operating instructions? 2

Did our staff provide clear operating instructions? 3

Did our staff provide clear operating instructions? 4

Did our staff provide clear operating instructions? 5

Did our staff satisfactorily address your questions?

Did our staff satisfactorily address your questions? 0

Did our staff satisfactorily address your questions? 1

Did our staff satisfactorily address your questions? 2

Did our staff satisfactorily address your questions? 3

Did our staff satisfactorily address your questions? 4

Did our staff satisfactorily address your questions? 5

Did our staff explain insurance & financial responsibility?

Did our staff explain insurance & financial responsibility? 0

Did our staff explain insurance & financial responsibility? 1

Did our staff explain insurance & financial responsibility? 2

Did our staff explain insurance & financial responsibility? 3

Did our staff explain insurance & financial responsibility? 4

Did our staff explain insurance & financial responsibility? 5

Was safety and emergency information presented?

Was safety and emergency information presented? 0

Was safety and emergency information presented? 1

Was safety and emergency information presented? 2

Was safety and emergency information presented? 3

Was safety and emergency information presented? 4

Was safety and emergency information presented? 5

	0	1	2	3	4	5
Has your experience with our company been positive?	Has your experience with our company been positive? 0	Has your experience with our company been positive? 1	Has your experience with our company been positive? 2	Has your experience with our company been positive? 3	Has your experience with our company been positive? 4	Has your experience with our company been positive? 5
Are you satisfied with the input you have in your care?	Are you satisfied with the input you have in your care? 0	Are you satisfied with the input you have in your care? 1	Are you satisfied with the input you have in your care? 2	Are you satisfied with the input you have in your care? 3	Are you satisfied with the input you have in your care? 4	Are you satisfied with the input you have in your care? 5
Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends?	Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 0	Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 1	Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 2	Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 3	Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 4	Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 5

Has your experience with our company been positive?

Has your experience with our company been positive? 0

Has your experience with our company been positive? 1

Has your experience with our company been positive? 2

Has your experience with our company been positive? 3

Has your experience with our company been positive? 4

Has your experience with our company been positive? 5

Are you satisfied with the input you have in your care?

Are you satisfied with the input you have in your care? 0

Are you satisfied with the input you have in your care? 1

Are you satisfied with the input you have in your care? 2

Are you satisfied with the input you have in your care? 3

Are you satisfied with the input you have in your care? 4

Are you satisfied with the input you have in your care? 5

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends?

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 0

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 1

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 2

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 3

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 4

Would you recommend Elite Home Medical & Respiratory, Inc. to family and friends? 5

Patient Satisfaction Survey

Question Title

* 1. Equipment

Question Title

* 2. Delivery

Question Title

* 3. Company

Question Title

* 4. Your Thoughts: