REFERRAL SATISFACTION SURVEY

It is our desire to strive for excellence. In an effort to help us maintain our high standards, please take a few moments to tell us how we are doing. Please complete this form and note the response that most closely matches your experience.

How do you send referrals? Check all that apply
- Phone
- Fax
- E-Prescribe
- Tell patient to contact Pharmacy Directly
The automated answering phone system*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
The process for sending in a referral*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
The amount of information we request for a referral*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
The length of time it takes us to handle your referrals (excluding insurance plan delays)*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
The quality, variety and availability of medication we carry*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
The helpfulness of our staff in meeting all your needs*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
The ease of sending in a pharmacy prescription*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
Our geographic service area is large enough to meet your referral needs Service Area By Other: AL, AK, AZ, AR, CA, CO, CT, DC, DE, FL, GA, HI, ID, IL, IN, IA, KS, KY, LA, ME, MD, MA, MI, MN, MS, MO, MT, NE, NV, NH, NJ, NM, NY, NC, ND, OH, OK, OR,PA, RI, SC, SD, TN, TX, UT, VT, VA, WA, WV, WI and WY.*
Extremely Satisfied Satisfied Dissatisfied Extremely Dissatisfied
What can we do to earn more of your business?
Name (optional) First Last
Location Info* City State / Province / Region
Date* MM slash DD slash YYYY

By submitting this form, you agree that you are not located within the European Economic Area

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