Memorial Home Infusion - Memorial Outpatient Pharmacy Services Patient/Client Satisfaction Survey

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* 1. Overall, how satisfied are you with Memorial Home Infusion?

Very satisfied

Somewhat satisfied

Neither satisfied nor dissatisfied

Somewhat dissatisfied

Very dissatisfied

"If dissatisfied or very dissatisfied" please provide further detail (optional)

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* 2. The home infusion pump worked properly.

Yes

N/A I did not use a home infusion pump

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* 3. The home infusion deliveries arrived as scheduled.

Always

Usually

Sometimes

Rarely

Never

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* 4. I knew how to contact pharmacy if I needed help with my home infusion therapy.

Yes

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* 5. Pharmacy personnel was available to address my questions during weekend or evening hours.

Yes

N/A I did not need to call for help on weekends or evening hours

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* 6. How satisfied are you with the counseling and education the pharmacist provided regarding your medication and its administration.

Very satisfied

Satisfied

Neither satisfied nor dissatisfied

Dissatisfied

Very dissatisfied

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* 7. I understood the explanation of my financial (cost) responsibilities for home infusion therapy.

Yes

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* 8. Using the table below, rate how often each staff were helpful.

	5 - Always	4 - Very Often	3 - Sometimes	2 - Rarely	1 - Never	N/A - Not Applicable
Onboarding Staff	Onboarding Staff 5 - Always	Onboarding Staff 4 - Very Often	Onboarding Staff 3 - Sometimes	Onboarding Staff 2 - Rarely	Onboarding Staff 1 - Never	Onboarding Staff N/A - Not Applicable
Delivery Staff	Delivery Staff 5 - Always	Delivery Staff 4 - Very Often	Delivery Staff 3 - Sometimes	Delivery Staff 2 - Rarely	Delivery Staff 1 - Never	Delivery Staff N/A - Not Applicable
Billing Staff	Billing Staff 5 - Always	Billing Staff 4 - Very Often	Billing Staff 3 - Sometimes	Billing Staff 2 - Rarely	Billing Staff 1 - Never	Billing Staff N/A - Not Applicable
Pharmacy Staff	Pharmacy Staff 5 - Always	Pharmacy Staff 4 - Very Often	Pharmacy Staff 3 - Sometimes	Pharmacy Staff 2 - Rarely	Pharmacy Staff 1 - Never	Pharmacy Staff N/A - Not Applicable
Nursing Staff	Nursing Staff 5 - Always	Nursing Staff 4 - Very Often	Nursing Staff 3 - Sometimes	Nursing Staff 2 - Rarely	Nursing Staff 1 - Never	Nursing Staff N/A - Not Applicable

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* 9. How likely is it that you would recommend Memorial Home Infusion to a friend or family member?

NOT AT ALL LIKELY

EXTREMELY LIKELY

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* 10. Please provide any comments or questions you may have

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* 11. If you would like to be contacted, please provide your name, email, and phone number. (optional)

Name

Email Address

Phone Number

Thank you for using Memorial Home Infusion. We hope you were happy with our service. If you were, would you consider leaving us a Google review? This helps us to continue providing great service and helps others like you to find us.

Thank you in advance!

Please click Memorial Home Infusion Google Review