Pharmacy Survey.

Contact information: Name   Organization   Address   City and State   ZIP Code   Email address   Phone   What is your preferred primary pharmacy? How did you find out about this pharmacy? Please select one or more ... From a medical doctor From a friend or family member Referred from the emergency room at the hospital From my medical plan's provider listing From a chiropractor Other Do you have a personal pharmacist (a pharmacist you usually consult with)? Yes No How did you pay for your medications? Self Pay Cash Insurance- Other Insurance- HMO Medicare Medicaid Medi-Cal Is this a convenient way of payment? To what extent do you agree with the listed below   Agree/Disagree Please comment The amount of waiting time in the reception area was just right                      Totally Agree Somewhat Agree Neither Agree, Nor Disagree Somewhat Disagree Totally Disagree The amount of time the pharmacist spent with you was just right                      Totally Agree Somewhat Agree Neither Agree, Nor Disagree Somewhat Disagree Totally Disagree Answers to your medical questions were prompt                      Totally Agree Somewhat Agree Neither Agree, Nor Disagree Somewhat Disagree Totally Disagree Medical information/advice was available and clear                      Totally Agree Somewhat Agree Neither Agree, Nor Disagree Somewhat Disagree Totally Disagree What is your opinion as to the issues listed below?   Poor Good Excellent Please comment your choice Convenience of operation hours Appearance of the office Reception Room quality Parking Security level Does your pharmacy offer a prescription mail service? Yes No Do not know Would you be interested in having the option of having your prescriptions mailed to you? Yes No I already use this service What other services would you like to see your pharmacy healthcare partner offer? What is your level of trust in ordering prescriptions:   Level of trust Via the Internet                      Very high High Standard Low Very low By email                      Very high High Standard Low Very low By postal mail                      Very high High Standard Low Very low By phone                      Very high High Standard Low Very low By fax                      Very high High Standard Low Very low How many prescriptions do you have filled monthly? How likely are you to refer your friends and neighbors to this institution? Highly Likely Likely Neutral Unlikely Highly Unlikely Add any other suggestions or information that you think could improve the service.

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