Patient Satisfaction Survey.docx
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PATIENT SATISFACTION SURVEY
VETERAN________________________________________________________________
LAST 4___________________ DATE OF DELIVERY______________________________
| 1. WERE YOU PLEASED WITH THE PRODUCTS YOU RECEIVED FROM**********? YES | NO | |||||
| 2. WERE THE PRODUCTS RECEIVED IN A TIMELY MANNER? | YES | NO | ||||
| 3. WERE THE TECHNICIANS WHO SET UP AND INSTRUCTED YOU HELPFUL AND DID THEY ANSWER YOUR QUESTIONS? | YES | NO | ||||
| 4. ARE YOU PLEASED WITH **************** SERVICE? | YES | NO | ||||
| 5. IS THERE ANYTHING WE CAN DO FOR YOU AT THIS TIME? | YES | NO |
6. IF SO, WHAT CAN WE DO TO HELP _________________________________________________ ______________________________________________________________________________
WHO CONTACTED VETERAN______________________________________________________________ DATE OF CONTACT_______________________
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