Customer Survey

Demographics

The following information will help us learn more about the people who use CareSite. This information is completely voluntary.

Zipcode:

Your 5-digit zip code.

Gender:

Male

Female

Age Group:

What factor most influences your decision in choosing a pharmacy?: *

Efficiency of service

Professionalism of staff (i.e., attitude of staff and understanding)

Location of pharmacy

Quality of pharmacist / staff interaction

Services offered (i.e., refill requests to doctors and handling of insurance claims problems)

Your Visit

Was this your first time visiting a CareSite Pharmacy?: *

yes

Will you return to a CareSite Pharmacy in the future?: *

yes

undecided

If you do not intend to return, how can CareSite win back your trust?:

How long did you wait for your prescription to be filled?: *

Less than 10 minutes

10-15 minutes

Greater than 15 minutes

Ratings

Please rate the following using this scale: [5 = Highest rating, 4 = Above Average, 3 = Average rating, 2 = Below Average, 1 = Unacceptable]

How would you rate the courteousness/helpfulness of the CareSite staff?: *

Please rate the medication information you received (written and/or verbal): *

Please rate your overall satisfaction with your interaction in the CareSite pharmacy: *

Market Research

The following section contains market research. All questions in this section are optional.

Would you be interested in having your prescription confidentially delivered to your place of work?:

yes

If yes, please fill out your company’s name and address below:

Company Name:

Company Address:

Would you be interested in mail-order 90-day subscription refills?:

yes

Comments / Suggestions:

Email Address:

Your email address will be kept completely confidential.

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