Feedback Survey

Thank you for taking a few minutes out of your day to share your experience with us. Your feedback is incredibly valuable as we continue to improve patient care!

* Required

Name*

First Last

Prior to your appointment, please rate how our Office Staff performed with the following:

Friendliness, professionalism, and helpfulness*

Ability to clearly explain how the process works*

Communication regarding the status of your order*

Responsiveness to questions or concerns*

Transparency about availability when scheduling a date for the CPAP Setup*

The Office Staff reviewed my insurance benefits and any compliance requirements.*

The Office Staff informed me of any potential out of pocket costs.*

Did you receive education from a Respiratory Therapist?*

No
Yes

Date of Service Appointment*

Location of Service Appointment*

Name of your Respiratory Therapist*

Please rate how our Respiratory Therapist performed with the following:

Outreach for appointment reminder and mask selection*

Friendliness and professionalism with patient care*

Responsiveness to questions during the setup process*

Explanation of equipment and its proper application and use*

Explanation of how to maintain equipment*

Explanation of our long term support and follow up*

I have a clear understanding of how to get CPAP supplies in the future.*

Did you have a Telemedicine Appointment?*

No
Yes

Please answer the following questions about your Telemedicine experience

I was well prepared and able to easily access the meeting link for my Telemedicine Appointment.*

I felt the Telemedicine Appointment was thorough and easy to follow along with clarity of equipment shown by the Respiratory Therapist.*

Would you be open to doing another Telemedicine Appointment in the future?*

Yes, I enjoyed it
No, I prefer Face-To-Face Appointments

Were you reminded by our team to make a follow-up appointment with your provider?*

Would you recommend Quality DME to your family and friends?*

Please share any additional comments or suggestions below

What equipment was supplied to you?

Prior to your appointment, please rate how our Office Staff performed with the following:

Please rate how our Respiratory Therapist performed with the following:

Please answer the following questions about your Telemedicine experience

Please rate how our Office Staff performed with the following:

Contact Us

Lorton, VA – Main Office

Columbia, MD

Fredericksburg, VA

Richmond, VA

Virginia Beach, VA

Links

Order Supplies, Plant A Tree

Sign up for our Newsletter!

What equipment was supplied to you?

Prior to your appointment, please rate how our Office Staff performed with the following:

Please rate how our Respiratory Therapist performed with the following:

Please answer the following questions about your Telemedicine experience

Please rate how our Office Staff performed with the following:

Follow Us

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Contact Us

Lorton, VA – Main Office

Columbia, MD

Fredericksburg, VA

Richmond, VA

Virginia Beach, VA

Links

Order Supplies, Plant A Tree

Sign up for our Newsletter!