Patient Survey

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Patient Satisfaction Survey

To help us in our commitment to quality assurance, please complete the following survey and return in the self addressed stamped envelope.

Patient Name

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Date of Delivery

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Items Delivered

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Delivery Technician

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Were you properly instructed on the use of the supplies/equipment?

YesNo Invalid Input

Was your delivery technician friendly?

YesNo Invalid Input

Were all of your questions answered?

YesNo Invalid Input

Did the delivery technician go over all of your paperwork?

YesNo Invalid Input

Were you given warranty/repair information?

YesNo Invalid Input

Was our return policy explained to you?

YesNo Invalid Input

Were you told how to voice a complaint to us?

YesNo Invalid Input

Was financial responsibility discussed with you?

YesNo Invalid Input

Did the delivery technician go over home safety of the equipment?

YesNo Invalid Input

How would you rate Medicare’s rules regarding home medical equipment and the impact these rules have on your access to the products and services you believe you require?

ExcellentGoodFairPoor Invalid Input

How would you rate your overall satisfaction with the delivery experience on a scale of 1-10? (10 being exceptional and 1 being poor)

12345678910 Invalid Input

Notes/Comments

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(*)

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Contact & Forms

Give us a call!
Phone: 508-301-2644
Fax: 508-779-6933

Email Customer Service

New Patient Registration

Supply Reorder Form

Patient Survey Form

Downloadable Forms

Patient Packet

Supplier Standards

New England Medical Supplies Inc.
6 N Main St. Suite 303
Uxbridge, MA 01569

Phone: 508-301-2644
Fax: 508-779-6933

Customer Service Email

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