Monroe Carell Jr. Children's Hospital at Vanderbilt

Date of Your Pharmacy Visit (mm/dd/yy)


Please rate your visit to the Children’s Hospital Outpatient Pharmacy in the following areas:

1. The cleanliness and neatness of the pharmacy
Excellent    Very Good    Good    Fair    Poor   

2. Completeness and accuracy of your prescription order
Excellent    Very Good    Good    Fair    Poor   

3. Wait time in the pharmacy to drop off your prescription
Excellent    Very Good    Good    Fair    Poor   

4. Wait time in the pharmacy to pick up your prescription
Excellent    Very Good    Good    Fair    Poor   

5. Courtesy and respect shown to you by the cashier today
Excellent    Very Good    Good    Fair    Poor   

6. Courtesy and respect shown to you by the pharmacist today
Excellent    Very Good    Good     Fair    Poor    N/A (did not speak with pharmacist)   

7. How your questions or concerns were addressed by the pharmacist
Excellent    Very Good    Good     Fair    Poor    N/A (did not speak with pharmacist)   

8. Respect for your privacy and confidentiality of your personal information
Excellent    Very Good    Good     Fair    Poor   

9. Your understanding of the instructions or directions on your medication(s)
Excellent    Very Good    Good     Fair    Poor   

10. Overall satisfaction with the service you received today
Excellent    Very Good    Good     Fair    Poor   

11. Likelihood of recommending this pharmacy to others
Excellent    Very Good    Good     Fair    Poor   

12. Would you like to mention any person for any reason?


13. Please make any suggestion(s) that would improve our service to you