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Patient Satisfaction Survey
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Satisfaction Survey
Referral Source
Satisfaction Survey
Fill Out The Referral
Source Satisfaction Survey
Referral Source Satisfaction Survey
In an effort to continuously improve our services, please take a few minutes to complete our
11 question
survey.
** = Required
Name: **
Referral Name (optional):
In an effort to continuously improve our services, please take a few minutes to complete our survey.
Please rate each item on a scale from 1 - 5
1 = Strongly Disagree
2 = Do Not Agree
3 = Somewhat Agree
4 = Agree
5 = Strongly Agree
N/A = Not Applicable - You did not have this service and can not rate it
Customer Service was easily accessible (reasonable hold times)
N/A
1
2
3
4
5
Ease of placing an order/referral process
N/A
1
2
3
4
5
Intake staff was knowledgeable, efficient, presented options to consider and questions were appropriate
N/A
1
2
3
4
5
Our range of services met your needs
N/A
1
2
3
4
5
Ease of our referral management process (in the event we could not handle your referral and we referred it out to another provider)
N/A
1
2
3
4
5
The turnaround time from placing the referral to the patient receiving services met your expectations
N/A
1
2
3
4
5
Quality of care, products and services met your expectations
N/A
1
2
3
4
5
Respira Medical is a reliable provider who fulfills its promises and offers timely follow up
N/A
1
2
3
4
5
Our after hours service responded to your needs promptly and efficiently
N/A
1
2
3
4
5
The Patient Account Representative that calls on your office is knowledgeable and efficient
N/A
1
2
3
4
5
You would use Respira Medical again and/or recommend us for medical supplies and medical equipment services.
N/A
1
2
3
4
5
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