Survey | Monahans Pharmacy (432) 943-4212

Patient Name

Date of Service

Drug Name (Optional)

Equipment Type (Optional)

Responses to questions, concerns were addressed in a timely manner?

Yes

No

N/A

Was service friendly, prompt and courteous?

Yes

No

N/A

Satisfied with the time spent with the pharmacist?

Yes

No

N/A

Did pharmacist/staff request info on other medication currently prescribed?

Yes

No

N/A

Satisfied with the medication counseling/instructions provided by the pharmacist?

Yes

No

N/A

Satisfied with the length of time for prescription processing?

Yes

No

N/A

Received info on patient rights and responsibilites (posted on counseling room)?

Yes

No

N/A

Satisfied with serivce and would recommend to others?

Yes

No

N/A

Additional feedback on pharmacy services:

Equipment/Supplies were delivered in a timely manner?

Yes

No

N/A

Equipment/Supplies were ready for patient use upon delivery?

Yes

No

N/A

Received/Understood instructions on proper use of equipment supplies?

Yes

No

N/A

Feel confident to operate/use equipment supplies?

Yes

No

N/A

Received info on rights/responsibilities, complaint process, billing, contact numbers and reasons?

Yes

No

N/A

Response to my questions/concerns were addressed in a timely manner?

Yes

No

N/A

Satisfied with equipment or supplies?

Yes

No

N/A

Satisfied with service and would recommend to others?

Yes

No

N/A

Additional feedback on durable medical equipment:

Provider Satisfaction Survey

Pharmacy Services:

Durable Medical Equipment Only: