Customer Feedback Form

Customer Feedback Form

Please do not include details of medications on this form
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you filling this out on behalf of yourself?

MyselfSomeone else
If filling out on behalf of someone else, whom?

First NameLast Name
Please choose from the following options:

Suggestion or 5 star experienceComplaint
We are very sorry to hear about this and will begin an investigation right away. Please select one of the following:

Possible Side EffectDelivery ProblemPreparation not to satisfactionCommunication IssuePharmacy Team Member IssueOther
Please describe in detail your selection. Please provide date, time and any other relevant details, so we can get back to you faster.
What would you like us to do?
Someone will be in touch with you within 48 business hours- is this acceptable to you? We will be calling at the number listed above.

YesNo
What was so amazing and who can we thank on your behalf?
Would you mind quickly leaving your review online as well? As a small business these reviews help us tremendously!

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Please allow the Executive Team 2 business days to respond to your feedback.
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Should be Empty:

Please allow the Executive Team 2 business days to respond to your feedback.