Customer Satisfaction Survey

Please mark the answer that best describes your satisfaction.

Excellent — 5 | Good — 4 | Fair — 3 | Poor — 2 | Very Poor — 1

Which products and services did you receive? (check all that apply)

Respiratory Equipment Rehabilitation & Mobility Medical Supplies Other

Did the staff deliver and explain your Bill Of Rights

Yes No

Were you satisfied with the training provided to you?

Yes No

Were your deliveries timely? (If applicable)

Yes No

Please rate the courtesy/friendliness of our staff.

1 2 3 4 5

Please rate your understanding and knowledge of your financial responsibility (if any) when you received your equipment.

1 2 3 4 5

Please rate the cleanliness and working condition of your equipment when received.

1 2 3 4 5

Overall how would you rate our service

1 2 3 4 5

Name

Phone

Comments

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DuBois Medical Supply 320 Liberty Blvd. DuBois, PA 15801

Phone: (814) 375-1100
Toll Free: (800) 222-2023
Fax: (814) 375-9796