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CALL: 315-457-8337 OR EMAIL: INFO@MEDISOURCEMANAGEMENT.COM

Patient Satisfactory Survey

How easy was it to schedule an appointment?

Very easy
Difficult

Upon arrival, how would rate your experience with our administrative staff?

Friendly/Helpful
Pleasant
Rude
Not acknowledged

For your scheduled appointment, were you seen:

Before your appointment
On time
Just after
Long after
I was late

Were your financial obligations explained to you?

Yes
No
Not Applicable

Were the instructions regarding the use and care of your device useful?

Very useful
Somewhat useful
Not useful
I didn’t get instructions

Were you instructed in the purpose and function of the device(s)?

Yes
No
I don’t remember

Were you instructed about the potential risks, benefits and precautions associated with the device(s)?

Yes
No
I don’t remember

Were you instructed on whom to contact if a problem develops?

Please rate your overall satisfaction with the care you received.

Satisfied
Neutral
Unsatisfied

Would you like for us to contact you? If so, please provide your name and phone number.

Please provide name & number

Additional comments

Medisource Management | 145 Dwight Park Circle | Syracuse | New York | 13209

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