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We appreciate your comments and feedback about the service we provide at Pensacola Apothecary. Please answer any questions that apply to you.

Enter prescription numbers and/or the supplements used: (optional)

How do you rate the overall service you received at Pensacola Apothecary?

How well did the pharmacy meet your needs as a patient?

Will you return to Pensacola Apothecary should you need compounded prescriptions again?

	Yes
	No

Did you have any problems taking these medications/supplements?

	Yes
	No

If yes, please explain.

Did we explain how to use your medication clearly?

	Yes
	No

Did you like the consistency and/or flavor of your medication?

	Yes
	No

List flavor

Did the dosage form meet your individual needs?

	Yes
	No

Indicate Dosage Form:

	Capsules
	Lozenges/Troches
	Transdermal Gel or Creams
	Oral Delivery Systems such as flavored lollipops or chewable gummy bears
	Suspensions/oral solutions such as eye drops, ear drops, sterile injections or nasal sprays
	Suppositories

Comments:
Yes/no this dosage form worked for me because...

Please inlcude any additional comments or suggestions. We welcome your feedback.