Customer Satisfaction Survey For Evaluation Of Pharmacist Consultants

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CUSTOMER SATISFACTION SURVEY
FOR EVALUATION OF PHARMACIST CONSULTANTS
This evaluation will take 2 minutes to complete. We value your time and your opinions. The information you provide to
us is important and we will use it to make any process improvements that are identified. You will be emailed this form
periodically, requesting your input. You can also save a copy of this and complete it as you identify needs for
improvement or you want to share something positive about the consulting processes. Please print this form,
complete, and fax back to FAX# 502-420-2805 Attention: Georgia. Thank-you for your participation.
Today’s date: __________________ Name of Consultant: _______________________________________________
Last date of consulting: ________________ Location(s) completed: _______________________________________
________________________________________________________________________________________________
Date reports received for locations: ________________ Were they complete? ________________________________
If NO, please explain: ______________________________________________________________________________
Were consulting audits done on time
? ____________________
(according to regulations, operational needs, or at nursing request)
Was this a scheduled consulting time? __________________________________ (last date of consulting, listed above)
Did Pharmacist communicate with you about the findings?
(Identified patterns or concerns found in the audits): _________________
________________________________________________________________________________________________________________________
Is there anything else you need from your consultant? ___________________________________________________
________________________________________________________________________________________________
Please make any other comments that are not categorized above: __________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Thanks for your feedback!
________________________________________________ ______________________________________________
Signature
Printed Name
___________________________________________________________
Contact Number
Follow up: ______________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________

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