Medication Dispensing Feedback Survey
Please share your feedback on your recent experience with our medication dispensing service. Your responses help us improve our service.
Are you completing this survey as a:
*
Patient
Caregiver
Other
Date of medication dispensing visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Pharmacy name or location
*
Please rate the following aspects of your medication dispensing experience:
*
Rows
Very Poor
Poor
Fair
Good
Excellent
Ease of receiving medication
1
2
3
4
5
Clarity of instructions provided
6
7
8
9
10
Staff professionalism and courtesy
11
12
13
14
15
Privacy during the process
16
17
18
19
20
Cleanliness of the pharmacy
21
22
23
24
25
How satisfied are you with the overall medication dispensing process?
*
1
2
3
4
5
How long did you wait to receive your medication?
*
Please Select
Less than 5 minutes
5-10 minutes
11-20 minutes
More than 20 minutes
Did you experience any issues or concerns during the medication dispensing process?
Long wait time
Incorrect medication or dosage
Unclear instructions
Unprofessional staff behavior
Other
How likely are you to recommend this pharmacy to others?
*
Not at all likely
1
2
3
4
5
6
7
8
9
Extremely likely
10
1 is Not at all likely, 10 is Extremely likely
Please share any suggestions or comments to help us improve our medication dispensing service.
Please provide your name (optional)
First Name
Last Name
Submit Feedback
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