Children's Medical Services Quality Survey

Hi there! We want to know how we can be better!

I have received info on my Rights & Responsibilities, complaint process, billing, contact numbers, and reasons to notify the supply company.

I acknowledge that I received this information.

Basic Information

Patient Name:

Current Phone:

Email Address:

Equipment/Supply Type:

Date of Last Delivery/Service:

Delivery Tech Name (leave blank if unknown):

Equipment Make or Serial # (if applicable):

Patient Status:

New Existing

1. Ease of placing an order or setting up a new account?

2. Courteous and Knowledgeable customer service?

3. Staff responded promptly to my needs & provided solutions?

4. Order processed quickly and accurately?

5. Selection and quality of merchandise?

6. Products correct and delivered in a timely manner?

7. How do you rate our overall service?

Please indicate any employee(s) that went above and beyond to provide excellent service:

Please elaborate on how the employee provided excellent service (optional):

Are you receiving enough supplies every month?

Answer:

Are you happy with the brand we're providing you?

Answer:

Other suggestions or comments to improve our service with you:

Submit Form

Please only click once.