AFFINITY MEDICAL SUPPLY
Patient Satisfaction Survey

Your satisfaction with our service is very important to us. We need your help by letting us know if we are doing a good job, or if there are areas where we can improve. Please take the time to fill in this short survey.

Choose one answer for each of the following questions on a scale of 1-5 Strongly Disagree to Strongly Agree.

1 = Strongly Disagree, 2 = Disagree, 3 = Neutral, 5 = Strongly Agree.
1. The equipment and/or supplies were delivered on time. 1 2 3 4 5 N/A
2. The equipment was clean when delivered. 1 2 3 4 5 N/A
3. The equipment was in good working order when delivered. 1 2 3 4 5 N/A
4. The instructions were adequate for safe use of the equipment. 1 2 3 4 5 N/A
5. The staff was courteous and helpful. 1 2 3 4 5 N/A
6. The financial responsibilities about my bill were explained to me. 1 2 3 4 5 N/A
7. Overall the services I received were to my satisfaction. 1 2 3 4 5 N/A
8. I would recommend your service to my friends and family. 1 2 3 4 5 N/A
9. Overall, I would rate my health today as: Excellent Good Fair Poor
Additional Comments
Would you like to be included on our email mailing list for updates about new products? If so, please include your email address.
Email Address
Name (optional) Date


Affinity Medical Supply • Hwy. 82-62 • Wolfforth, TX 79382 • (806) 771-0335