Patient Satisfaction Survey

Questions

Was the equipment (and supplies if applicable) delivered/dispensed accurately?*

Yes

No

Were the training, education materials, and consultations effective in educating you or your caregiver on your equipment (and supplies if applicable)?*

Yes

No

Was Carefluent Connect staff courteous and helpful?*

Yes

No

Were your financial responsibilities explained to you?*

Yes

No

Did the services provided meet your expectations and make a positive impact on the outcome of your care?*

Yes

No

Would you recommend our services to friends and family?*

Yes

No

Would you like our Carefluent Connect staff to contact you for additional follow-up?*

Yes

No

Name

Best Method of Contact

Email

Phone

Email Address

Phone Number

Comments (Optional)