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XXXX Safety Follow-Up Survey
0%
Exit Survey
 
 
Hello:
You are invited to participate in our safety follow-up survey as part of the care you received. It will take approximately 60 seconds to complete the questionnaire.

Your participation is completely voluntary and if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. Your survey responses will be strictly confidential. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact JG at 555-555-5555 or by email at [email protected].

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.
 
 
 
Did you fill your prescription?
 
Yes
 
No
 
Comments:
 

 
 
 
Did you have any side effects from your prescription?
 
Yes
 
No
 
Comments:
 

 
 
 
Did you have to follow-up for the same ailment?
 
No
 
Yes, I went to my Primary Care Physician
 
Yes, I went to Urgent Care
 
Yes, I went to the Emergency Room
 
Other:
 

 
 
Please rate the following:
Your Provider
Overall Experience
 
 
 
Comments/Suggestions:
   
 
Thank you for your time today. We hope you will think of XXXX for all of your low-acuity ailment needs.
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