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Patient Questionnaire

Question Title

* 1. Please indicate your level of satisfaction in regards to your contact with Village.

Please reply rating your experience using a 9 point scale where 1 is the worst experience and 9 is the best experience.

	N/A	1	2	3	4	5	6	7	8	9
Customer Service	Customer Service N/A	Customer Service 1	Customer Service 2	Customer Service 3	Customer Service 4	Customer Service 5	Customer Service 6	Customer Service 7	Customer Service 8	Customer Service 9
Telephone Response Time	Telephone Response Time N/A	Telephone Response Time 1	Telephone Response Time 2	Telephone Response Time 3	Telephone Response Time 4	Telephone Response Time 5	Telephone Response Time 6	Telephone Response Time 7	Telephone Response Time 8	Telephone Response Time 9
Courtesy of our Personnel	Courtesy of our Personnel N/A	Courtesy of our Personnel 1	Courtesy of our Personnel 2	Courtesy of our Personnel 3	Courtesy of our Personnel 4	Courtesy of our Personnel 5	Courtesy of our Personnel 6	Courtesy of our Personnel 7	Courtesy of our Personnel 8	Courtesy of our Personnel 9

Please share your experience.

Question Title

* 2. How satisfied were you with the way you received your order?

Please reply rating your experience using a 9 point scale where 1 is the worst experience and 9 is the best experience.

	N/A	1	2	3	4	5	6	7	8	9
Timeliness of your Delivery	Timeliness of your Delivery N/A	Timeliness of your Delivery 1	Timeliness of your Delivery 2	Timeliness of your Delivery 3	Timeliness of your Delivery 4	Timeliness of your Delivery 5	Timeliness of your Delivery 6	Timeliness of your Delivery 7	Timeliness of your Delivery 8	Timeliness of your Delivery 9
Pickup at one of our locations	Pickup at one of our locations N/A	Pickup at one of our locations 1	Pickup at one of our locations 2	Pickup at one of our locations 3	Pickup at one of our locations 4	Pickup at one of our locations 5	Pickup at one of our locations 6	Pickup at one of our locations 7	Pickup at one of our locations 8	Pickup at one of our locations 9
Packaging	Packaging N/A	Packaging 1	Packaging 2	Packaging 3	Packaging 4	Packaging 5	Packaging 6	Packaging 7	Packaging 8	Packaging 9

Please share your experience:

Question Title

* 3. If you used any of our educational resources, did you find them helpful?

Please reply rating your experience using a 9 point scale where 1 is the worst experience and 9 is the best experience.

	N/A	1	2	3	4	5	6	7	8	9
Online Video MED Series (Video Injection Lessons)	Online Video MED Series (Video Injection Lessons) N/A	Online Video MED Series (Video Injection Lessons) 1	Online Video MED Series (Video Injection Lessons) 2	Online Video MED Series (Video Injection Lessons) 3	Online Video MED Series (Video Injection Lessons) 4	Online Video MED Series (Video Injection Lessons) 5	Online Video MED Series (Video Injection Lessons) 6	Online Video MED Series (Video Injection Lessons) 7	Online Video MED Series (Video Injection Lessons) 8	Online Video MED Series (Video Injection Lessons) 9
Our website, www.villagefertilitypharmacy.com	Our website, www.villagefertilitypharmacy.com N/A	Our website, www.villagefertilitypharmacy.com 1	Our website, www.villagefertilitypharmacy.com 2	Our website, www.villagefertilitypharmacy.com 3	Our website, www.villagefertilitypharmacy.com 4	Our website, www.villagefertilitypharmacy.com 5	Our website, www.villagefertilitypharmacy.com 6	Our website, www.villagefertilitypharmacy.com 7	Our website, www.villagefertilitypharmacy.com 8	Our website, www.villagefertilitypharmacy.com 9
Quick Start Guide (included with your order)	Quick Start Guide (included with your order) N/A	Quick Start Guide (included with your order) 1	Quick Start Guide (included with your order) 2	Quick Start Guide (included with your order) 3	Quick Start Guide (included with your order) 4	Quick Start Guide (included with your order) 5	Quick Start Guide (included with your order) 6	Quick Start Guide (included with your order) 7	Quick Start Guide (included with your order) 8	Quick Start Guide (included with your order) 9
Medication Storage Instructions (included with your order)	Medication Storage Instructions (included with your order) N/A	Medication Storage Instructions (included with your order) 1	Medication Storage Instructions (included with your order) 2	Medication Storage Instructions (included with your order) 3	Medication Storage Instructions (included with your order) 4	Medication Storage Instructions (included with your order) 5	Medication Storage Instructions (included with your order) 6	Medication Storage Instructions (included with your order) 7	Medication Storage Instructions (included with your order) 8	Medication Storage Instructions (included with your order) 9

Please share your experience.

Question Title

* 4. Did you experience any problems with your order?

Yes

No

Please share your experience.