Thank you for allowing us to provide you Pharmacy services.  Please take a few minutes to give us your feedback on your experience.  We value your comments and welcome any suggestions you may have to improve our services. 

MARKING INSTRUCTIONS:
Please choose the most appropriate option for each question below.  
Please explain any less than satisfied response(s) in the comment section below.

*1.Email Address:(Required.)

2.Please tell us about yourself (optional)

Name:

Address:

Address 2

City/Town:

State/Province:

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ZIP/Postal Code:

Phone Number:

3.How would you rate your level of satisfaction with the following?

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Overall satisfaction with Rosemont Specialty Pharmacy

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Meeting your service expectations

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Timeliness of the delivery of your medication

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Accuracy of your order

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Helpfulness of the information you receive about your medication

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Ability to reach a person by phone who could answer your questions

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Explanation of what you personally will pay after your insurance pays

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Explanation of your insurance benefits

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Explanation on how you can refill your medication

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Explanation of whom to call if there is an issue with your order

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Condition of medication when filled/received

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

Staff knowledge of health condition

Very Satisfied

Satisfied

Somewhat Satisfied

Neutral

Somewhat Dissatisfied

Dissatisfied

N/A

4.How can we improve our services?

5.Comments: