SRRX Patient Satisfaction Survey

SRRX Patient Satisfaction Survey
We at Santa Rosa Pharmacy take great pride in satisfying each of hour individual clients’ pharmaceutical needs. We want to know how we’re doing and we need your assistance! Please tell us how satisfied your are with the services and care provided by our pharmacy.
Date

MonthDayYear
Date
Who is filing out the survey?

PatientCaregiverOther
Insurance Type

MedicareMedicaidAetnaAnthemBCBSCignaHumanaPrime TherapeuticsUnited healthcareOther
Care Planning: How satisfied were you with the process of starting service with Santa Rosa Pharmacy, including understanding your care plan and your financial responsibility?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Delivery: How satisfied are you with the accuracy and timeliness of the delivery of your products?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Quality: How satisfied are you with the quality of care provided by Santa Rosa Pharmacy?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Outcomes: How would you rate the products and for services you receive and their intended effect on the condition they are used to treat?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Clinical: How would you rate the clinical pharmacy services provided by Santa Rosa Pharmacy?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Communication: How satisfied are you with the level of politeness, helpfulness, and ease of contacting our employees?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Satisfaction: How would you feel referring others to our services?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Education: How would you rate the information/ education you received regarding our services?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Nursing: How satisfied are you with the nursing services provided?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Professionalism: How satisfied are you with the professionalism during your visit?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Comfort: How satisfied are you with the level of comfort your visit?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Wait time: How satisfied are you with the scheduling and time frame of your visit?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Cleanliness: How satisfied are you with the cleanliness at your visit?

5 Very Satisfied4 Somewhat Satisfied3 Neutral or N/A2 Somewhat Dissatisfied1 Very Dissatisfied
Do you have other comments, questions, or ways that we can improve our service to you?
If you receive home health services coordinated by Santa Rosa Pharmacy (list service):
Your feedback is important to us and your responses will help us serve you better.

The below fields are completely optional and you can choose to remain anonymous.
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: