Patient Satisfaction Survey

Thank you for allowing us to provide you Pharmacy services. Please take a few minutes to give us your feedback on your experience. We value your comments and welcome any suggestions you may have to improve our services.

MARKING INSTRUCTIONS:
Please choose the most appropriate option for each question below.
Please explain any less than satisfied response(s) in the comment section below.

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1. Email Address:

Email ID

2. Please tell us about yourself (optional)

Name

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone Number

3. How would you rate your level of satisfaction with the following?

	Very Satisfied	Satisfied	Somewhat Satisfied	Neutral	Somewhat Dissatisfied	Dissatisfied	N/A
Overall satisfaction with Rosemont Specialty Pharmacy	Very SatisfiedOverall satisfaction with Rosemont Specialty Pharmacy Very Satisfied	SatisfiedOverall satisfaction with Rosemont Specialty Pharmacy Satisfied	Somewhat SatisfiedOverall satisfaction with Rosemont Specialty Pharmacy Somewhat Satisfied	NeutralOverall satisfaction with Rosemont Specialty Pharmacy Neutral	Somewhat DissatisfiedOverall satisfaction with Rosemont Specialty Pharmacy Somewhat Dissatisfied	DissatisfiedOverall satisfaction with Rosemont Specialty Pharmacy Dissatisfied	N/AOverall satisfaction with Rosemont Specialty Pharmacy N/A
Meeting your service expectations	Very SatisfiedMeeting your service expectations Very Satisfied	SatisfiedMeeting your service expectations Satisfied	Somewhat SatisfiedMeeting your service expectations Somewhat Satisfied	NeutralMeeting your service expectations Neutral	Somewhat DissatisfiedMeeting your service expectations Somewhat Dissatisfied	DissatisfiedMeeting your service expectations Dissatisfied	N/AMeeting your service expectations N/A
Timeliness of the delivery of your medication	Very SatisfiedTimeliness of the delivery of your medication Very Satisfied	SatisfiedTimeliness of the delivery of your medication Satisfied	Somewhat SatisfiedTimeliness of the delivery of your medication Somewhat Satisfied	NeutralTimeliness of the delivery of your medication Neutral	Somewhat DissatisfiedTimeliness of the delivery of your medication Somewhat Dissatisfied	DissatisfiedTimeliness of the delivery of your medication Dissatisfied	N/ATimeliness of the delivery of your medication N/A
Accuracy of your order	Very SatisfiedAccuracy of your order Very Satisfied	SatisfiedAccuracy of your order Satisfied	Somewhat SatisfiedAccuracy of your order Somewhat Satisfied	NeutralAccuracy of your order Neutral	Somewhat DissatisfiedAccuracy of your order Somewhat Dissatisfied	DissatisfiedAccuracy of your order Dissatisfied	N/AAccuracy of your order N/A
Helpfulness of the information you receive about your medication	Very SatisfiedHelpfulness of the information you receive about your medication Very Satisfied	SatisfiedHelpfulness of the information you receive about your medication Satisfied	Somewhat SatisfiedHelpfulness of the information you receive about your medication Somewhat Satisfied	NeutralHelpfulness of the information you receive about your medication Neutral	Somewhat DissatisfiedHelpfulness of the information you receive about your medication Somewhat Dissatisfied	DissatisfiedHelpfulness of the information you receive about your medication Dissatisfied	N/AHelpfulness of the information you receive about your medication N/A
Ability to reach a person by phone who could answer your questions	Very SatisfiedAbility to reach a person by phone who could answer your questions Very Satisfied	SatisfiedAbility to reach a person by phone who could answer your questions Satisfied	Somewhat SatisfiedAbility to reach a person by phone who could answer your questions Somewhat Satisfied	NeutralAbility to reach a person by phone who could answer your questions Neutral	Somewhat DissatisfiedAbility to reach a person by phone who could answer your questions Somewhat Dissatisfied	DissatisfiedAbility to reach a person by phone who could answer your questions Dissatisfied	N/AAbility to reach a person by phone who could answer your questions N/A
Explanation of what you personally will pay after your insurance pays	Very SatisfiedExplanation of what you personally will pay after your insurance pays Very Satisfied	SatisfiedExplanation of what you personally will pay after your insurance pays Satisfied	Somewhat SatisfiedExplanation of what you personally will pay after your insurance pays Somewhat Satisfied	NeutralExplanation of what you personally will pay after your insurance pays Neutral	Somewhat DissatisfiedExplanation of what you personally will pay after your insurance pays Somewhat Dissatisfied	DissatisfiedExplanation of what you personally will pay after your insurance pays Dissatisfied	N/AExplanation of what you personally will pay after your insurance pays N/A
Explanation of your insurance benefits	Very SatisfiedExplanation of your insurance benefits Very Satisfied	SatisfiedExplanation of your insurance benefits Satisfied	Somewhat SatisfiedExplanation of your insurance benefits Somewhat Satisfied	NeutralExplanation of your insurance benefits Neutral	Somewhat DissatisfiedExplanation of your insurance benefits Somewhat Dissatisfied	DissatisfiedExplanation of your insurance benefits Dissatisfied	N/AExplanation of your insurance benefits N/A
Explanation on how you can refill your medication	Very SatisfiedExplanation on how you can refill your medication Very Satisfied	SatisfiedExplanation on how you can refill your medication Satisfied	Somewhat SatisfiedExplanation on how you can refill your medication Somewhat Satisfied	NeutralExplanation on how you can refill your medication Neutral	Somewhat DissatisfiedExplanation on how you can refill your medication Somewhat Dissatisfied	DissatisfiedExplanation on how you can refill your medication Dissatisfied	N/AExplanation on how you can refill your medication N/A
Explanation of whom to call if there is an issue with your order	Very SatisfiedExplanation of whom to call if there is an issue with your order Very Satisfied	SatisfiedExplanation of whom to call if there is an issue with your order Satisfied	Somewhat SatisfiedExplanation of whom to call if there is an issue with your order Somewhat Satisfied	NeutralExplanation of whom to call if there is an issue with your order Neutral	Somewhat DissatisfiedExplanation of whom to call if there is an issue with your order Somewhat Dissatisfied	DissatisfiedExplanation of whom to call if there is an issue with your order Dissatisfied	N/AExplanation of whom to call if there is an issue with your order N/A
Condition of medication when filled/received	Very SatisfiedCondition of medication when filled/received Very Satisfied	SatisfiedCondition of medication when filled/received Satisfied	Somewhat SatisfiedCondition of medication when filled/received Somewhat Satisfied	NeutralCondition of medication when filled/received Neutral	Somewhat DissatisfiedCondition of medication when filled/received Somewhat Dissatisfied	DissatisfiedCondition of medication when filled/received Dissatisfied	N/ACondition of medication when filled/received N/A
Staff knowledge of health condition	Very SatisfiedStaff knowledge of health condition Very Satisfied	SatisfiedStaff knowledge of health condition Satisfied	Somewhat SatisfiedStaff knowledge of health condition Somewhat Satisfied	NeutralStaff knowledge of health condition Neutral	Somewhat DissatisfiedStaff knowledge of health condition Somewhat Dissatisfied	DissatisfiedStaff knowledge of health condition Dissatisfied	N/AStaff knowledge of health condition N/A

4. How can we improve our services?

comment

5. Comments:

comment (copy)

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