Patient Satisfaction Survey

Name

First Last

This is not required.

Enter Email Confirm Email

Optional, your responses will be emailed to you.

1. The home infusion pump was clean when it was delivered(Required)

Yes	No	I did not use a home infusion pump

2. The home infusion pump worked properly(Required)

Yes	No	I did not use a home infusion pump

3. The home infusion medications and supplies arrived before I needed them(Required)

6. The home infusion nurse or pharmacist informed me of the possible side effects of the home infusion medication(Required)

Yes	No

5. The response I received to phone calls for help on weekends or during evening hours met my needs(Required)

6. The home infusion nurse or pharmacist informed me of the possible side effects of the home infusion medication(Required)

Yes	No

7. I understood the explanation of my financial responsibilities for home infusion therapy(Required)

Yes	No

8. Rate how often each staff were courteous(Required)

9. Rate how often each staff were helpful(Required)

10. I understood the instructions provided for:(Required)

11. I was satisfied with the overall quality of the services provided(Required)

12. I would recommend this home infusion company to my family and friends(Required)

Additional comments or suggestions

	Yes	No	Not Applicable
How to wash my hands
How to give the home infusion medication(s)
How to care for the IV catheter
How to store the home infusion medication(s)
How to use the home infusion pump