Patient Survey

Did the compounding pharmacy personnel provide clear and concise counseling and instructions on drug therapy and delivery devices?

	1	2	3	4	5

1 is Worst, 5 is Best

Were the compounding pharmacy personnel respectful, and did they offer immediate assistance?

	1	2	3	4	5

1 is Worst, 5 is Best

Did all members of the compounding pharmacy team act in a professional manner at all times?

	1	2	3	4	5

1 is Worst, 5 is Best

Did all members of the compounding pharmacy team appear to be well trained in their respective job duties?

	1	2	3	4	5

1 is Worst, 5 is Best

Was follow-up provided after the initial compounding consult or counseling session?

	1	2	3	4	5

1 is Worst, 5 is Best

Patient Evaluation and Survey Form