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Patient's Name: *
Referral:
Delivered by:
 
How satisfied were you with the on-time delivery of the equipment?
How helpful were our employees in explaining the use/care of your equipment?
How well were your financial responsibilities explained to you?
How well did the equipment work when it was delivered?
How clean was your equipment upon receipt?
How well did we explain the patient’s Bill of Rights to you?
After instruction, how comfortable did you feel in the use of your equipment?
How would you measure our overall responsiveness?
How did we respond to your phone call during business hours?
How did we respond to your phone call after business hours?
 
Comments:
 

     


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