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Service Evaluation Questionnaire

Dear Patient,

It is important to us that we provide you with the highest quality of care and the best overall experience. Please complete this questionnaire; your response helps us to continuously improve our services. You can also download and print out the form. Thank you.

Our Respiratory Therapist/Technician's Name:

Date of Visit:

Doctor's Name:

On a scale of 1 – 10 (1 = Poor and 10 = Excellent), please select the number of stars to rate your experience:

COURTESY

  1. Friendliness and courtesy of our Respiratory Therapist/Technician when they first arrived at your home/office.

COMMUNICATION

  1. Helpfulness of information as to what you can expect using your therapy?
  2. Did the therapist/technician clearly explain the equipment to you?
  3. Were your questions answered clearly?

IN-SERVICE

  1. Timeliness of the set-up procedure?
  2. Were instructions provided for follow-up care?
  3. Overall quality of care from the Therapist/Technician?
  4. Overall how would you rate the quality of care you received using Continued Care?

Would you recommend Continued Care to your family and friends?

If you have any additional comments please write them here:

OPTIONAL

Your Name:

Your E-mail:

Telephone:

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