Exemplary Provider Satisfaction Measure
A survey about the services provided by Synergy Medical Systems, LLC
Patient Name: *
Your answer
Person Completing Form (if different from patient)
Your answer
Date of service *
MM
/
DD
/
YYYY
State in which services were rendered. *
Equipment received *
Your answer
Equipment was delivered in a timely manner. *
Equipment was ready for patient use upon delivery. *
Received and understood instructions on proper application and use of equipment. *
Feel confident to operate/use equipment. *
Received info on my Rights & Responsibilities, complaint process, billing, contact numbers, and reasons to notify Synergy Medical Systems, LLC. *
Response to my questions, problems, concerns were addressed in a timely manner. *
Satisfied with the equipment. *
Satisfied with the service. Would recommend to others. *
Comments.
Your answer
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