Date of service: Physician:
Type of product or service received:

1. Was our equipment provided in clean and working order?
Yes No Doesn't Apply

2. Do you feel you received adequate instruction by the person who provided you with the equipment?
Yes No Doesn't Apply

3. Were our representatives courteous, friendly and helpful?
Yes No Doesn't Apply

4. Did you receive a copy of our billing and collection policies?
Yes No Doesn't Apply

5. Were your rights and responsibilities as a patient explained to your satisfaction?
Yes No Doesn't Apply

6. Was your set up scheduled and equipment delivered in a prompt and timely manner?
Yes No Doesn't Apply

7. Do you have our phone number and hours of business?
Yes No Doesn't Apply

8. Was it explained how to contact us after hours in the event you experience equipment failure that requires emergency service?
Yes No Doesn't Apply

9. Would you recommend us to your physician, family and friends?
Yes No Doesn't Apply

10. Overall how would you rate your experience with Performance Home Medical?
Excellent Satisfactory Poor

Additional comments:


Please have someone call me.
Name:
Telephone: