Patient Evaluation and Survey Form

( 1=Very Poor 2=Poor 3=Average 4=Good 5=Excellent )

Did pharmacy personnel provide clear and concise counseling and instructions on drug therapy and delivery devices?
Were the pharmacy personnel respectful, and did they offer immediate assistance?
Did all members of the pharmacy team act in a professional manner at all times?
Did all members of the pharmacy team appear to be well trained in their respective duties?
Was follow-up provided after the initial consult or counseling session?


Pharmacy Technician(s)
Delivery Personnel
Other Personnel