Client Satisfaction Survey Form

1. Was the service / supply provided in a timely manner?

1	2	3	4
5

2. Were you given a copy of the Patient Bill of Rights and Consent From?

1	2	3	4
5

3. Were those documents explained to you?

1	2	3	4
5

4. Were you given complete teaching / instructions on your care / supplies?

1	2	3	4
5

5. Were all your questions answered to your satisfaction?

1	2	3	4
5

6. Was the staff courteous, knowledgeable, and professional?

1	2	3	4
5

7. Were you instructed on who/where to call with questions or problems?

1	2	3	4
5

8. Were you satisfied with your care/service?

1	2	3	4
5

9. Would you recommend your agency to others?

1	2	3	4
5

Please tell us how we might be of better service to you:

Name

Date