Patient Satisfaction Survey

MedSupply is continually seeking to improve the products and services we provide. In order to adequately meet your needs, we require your feedback and suggestions. Please complete the survey. Thank you!
Please identify the service(s) you received by checking one or more of the following:
- Home Medical Equipment
- Orthotics & Prosthetics
- Respiratory Therapy
- Nutritional Services
Please take a moment to select the response that best describes your experience with MedSupply.
Courteousness and knowledge of clinician that fit device.
Thoroughness of operation and care instructions provided.
Courteousness and knowledge of customer service staff.
Timeliness in receiving device/services.
Involvement of you and/or family in selection of equipment.
Response of staff with any questions, problems, or concerns.
Level of respect staff showed to your home.
Overall, how would you rate services to you.
Your financial responsibilities were explained to you?
- Yes
- No
Would you recommend MedSupply to your friends and/or family?
- Yes
- No
What did you like most about our agency?
Please tell us what we can do to improve our rating:
Your Name:
Service date:
MM slash DD slash YYYY