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Referral Source Satisfaction Survey
Please rate how satisfied you are with the following:
*
1.
Practice Name and City
(Required.)
Practice Name
City
*
2.
Timeliness of starting your patient on therapy
(Required.)
Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
*
3.
Friendliness and helpfulness of staff
(Required.)
Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
*
4.
Assistance with insurance related issues
(Required.)
Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
*
5.
Communication about the status of your referral
(Required.)
Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
*
6.
How likely are you to refer patients to Palmetto Infusion in the future
(Required.)
Very Likely
Somewhat Likely
Neither Likely or Unlikely
Somewhat Unlikely
Very Unlikely
*
7.
Overall Satisfaction with Palmetto Infusion
(Required.)
Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
*
8.
Overall ease of utilizing Palmetto Infusion
(Required.)
Very Satisfied
Somewhat Satisfied
Neither Satisfied or Dissatisfied
Somewhat Dissatisfied
Very Dissatisfied
*
9.
What can we do to improve our services?
(Required.)
