Patient Satisfaction Survey

Patient Satisfaction Survey

At Infusion Solutions, we are committed to providing high quality, cost effective, personalized infusion care. We appreciate your feedback to help us meet these goals and improve our patient care.
1. The home infusion equipment was clean when it was delivered.

YesNoI did not use equipment
Comments:
2. The home infusion equipment worked properly.

YesNoI did not use equipment
Comments:
3. The home infusion medications and supplies arrived before I needed them.

AlwaysVery OftenSometimesRarelyNeverN/A
Comments:
4. I knew who to call if I needed help with my home infusion therapy.

YesNo
Comments:
5. The response I received to phone calls for help on weekends or during evening hours met my needs.

AlwaysVery OftenSometimesRarelyNeverN/A
Comments:
6. The home infusion nurse or pharmacist informed me of the possible side effects of the medication.

YesNo
Comments:
7. I understood the explanation of my financial responsibilities for home infusion therapy.

YesNo
Comments:

8. How often was staff courteous?

9. How often was staff helpful?

10. I understood instructions provided for:

	Yes	No	N/A
How to wash my hands
How to give home infusion medications
How to care for the IV catheter
How to store home infusion medications
How to use home infusion equipment

Comments:
11. I was satisfied with the overall quality of services provided.

Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
Comments:
12. I would recommend this home infusion company to my family and friends.

Strongly AgreeAgreeUncertainDisagreeStrongly Disagree
Comments:
Please provide any additional comments or suggestions regarding your infusion care:
Clinic location seen at
Bypass this question if received solely home infusion care.
County of residence
Consent to have my feedback used by Infusion Solutions for advertising purposes.*

I give consentI do not wish to give consent
Name*

First NameLast Name
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