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Patient Satisfaction Survey

At D&J Medical, our goal is to provide you with the services and products you need in a timely and professional manner. Your responses to this form will help us gauge how well we are doing and show us how we can improve. Please select the responses that match your experience with D&J. Thank you for your help.

Today's date:   June 17th, 2013

Location of your D&J Visit:

  1. Did our staff introduce themselves by name and title?

    2. Yes
    No

  2. Did you receive the pink copy of your prescription form?

    3. Yes
    No

  3. Did our staff educate you on the proper fitting and daily use of the product you received?

    4. Yes
    No

  4. Were you told how to contact D&J in case of a problem?

    5. Yes
    No

  5. Were you informed of your rights and responsibilities regarding financial obligations?

    6. Yes
    No

  6. Was the staff knowledgeable about our products?

    7. Yes
    No

  7. Was the staff courteous and professional?

    8. Yes
    No

Please add any comments about your visit here:

If you would like a response to your comments from D&J,
please complete the following:

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