Pt Satisfaction Survey

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PATIENT SATISFACTION SURVEY

Complete both surveys Survey 1 of 2

* Indicates required field

Patients Name *

First

Last

Your Name *

First

Last

Email *

Phone Number *

1. Professional, courteous, timely service provided by the staff *

Excellent Good Average Fair Poor

If Other please specify: *

2. My pain is being managed by current medication regime *

Excellent Good Average Fair Poor

If Other, please specify *

3. Instruction and / or treatments clearly and thoroughly explained by staff *

Excellent Good Average Fair Poor

If Other, please specify *

4. In all my contact with hospice staff, I feel that all my questions were answered appropriately *

Excellent Good Average Fair Poor

If Other, please specify *

5. Continuity of staff members providing care *

Excellent Good Average Fair Poor

If Other, please specify *

6. Services provided helped me/ my family meet all health needs *

Excellent Good Average Fair Poor

If Other, please specify *

7. The overall quality of services provided were *

Excellent Good Average Poor Fair

If Other, please specify *

Submit

Survey 2 of 2

* Indicates required field

Patients Name *

First

Last

Your Name *

First

Last

Email *

Phone Number *

8. I was notified of schedule changes in advance *

Excellent Good Average Fair Poor

If Other please specify: *

9. I was treated with a positive and helpful attitude by staff members *

Excellent Good Average Fair Poor

If Other, please specify *

10. I feel that enough time was taken by the field staff in providing care for me *

Excellent Good Average Fair Poor

If Other, please specify *

11. Home visits were made on day(s) and time(s) I was informed they would be *

Excellent Good Average Fair Poor

If Other, please specify *

12. I was informed of how to contact the hospice after hours *

Excellent Good Average Fair Poor

If Other, please specify *

13. Equipment and supplies were delivered on time *

Excellent Good Average Fair Poor

If Other, please specify *

14. Medication was delivered on time *

Excellent Good Average Fair Poor

If Other, please specify *

Submit

5301 Laurel Canyon Blvd. Suite 230. Valley Village CA 91607 Fax: 818.495.2481 24hr Hotline 818.232.8123

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