* = Required Information
1. Was our staff courteous, knowledgeable and respectful to you?
Yes
No
2. Were your questions and requests addressed appropriately and in a timely manner?
Yes
No
N/A
3. Did your medications, equipment and supplies arrive at the scheduled time?
Yes
No
4. Was your equipment clean and in good working condition?
Yes
No
N/A
5. Were there any safety issues that concerned you during therapy?
Yes
No
If yes, please explain below in #10.
6. Were your financial responsibilities explained to you?
Yes
No
7. Was your therapy successful?
Yes
No
8. Overall were you satisfied with our services?
Yes
No
9. Would you recommend us to others?
Yes
No
10. Full Name (Optional)
Phone (Optional)
11. Comments/Suggestions for improvement in safety and services:
Submit