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Patient/Family Member Survey


Please rate the Respiratory Care Services received. Select the response that best represents your feelings. If you had no experience with a particular service or item, skip to the next one. In the space provided below, please comment on any negative or positive experience you might have had.


General Questions
Date of Visit
Location of Care
Your Name
Your Phone Number
Your E-mail
(Please answer)
Age of Patient
Therapist identified his/her name and department upon entering room.
Concern was shown for my questions by the therapist.
What the treatment would be like was explained to me.
Equipment purpose was explained.
Therapist’s courtesy toward family or guests who accompanied you.
Bedside items were returned within reach after therapy.
Therapist’s concern for my comfort.
Therapist’s concern for my privacy.
(Please type as much as you'd like.)
Suggestions for Improvement
(Please type as much as you'd like.)


Quick Reference

Respiratory Care Services

Administrative Office
Pulmonary Function Lab

8AM-5PM Monday thru Friday
Ways to Give
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