Customer Feeback
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1. Appointment Summary
1
. POTENTRx Staff
Unacceptable
Below Average
Average
Above Average
Exceptional
Level of service
*
POTENTRx Staff Level of service Unacceptable
Level of service Below Average
Level of service Average
Level of service Above Average
Level of service Exceptional
Level of knowledge
Level of knowledge Unacceptable
Level of knowledge Below Average
Level of knowledge Average
Level of knowledge Above Average
Level of knowledge Exceptional
Appointment turnaround time
Appointment turnaround time Unacceptable
Appointment turnaround time Below Average
Appointment turnaround time Average
Appointment turnaround time Above Average
Appointment turnaround time Exceptional
Recognizes and responds to my needs
Recognizes and responds to my needs Unacceptable
Recognizes and responds to my needs Below Average
Recognizes and responds to my needs Average
Recognizes and responds to my needs Above Average
Recognizes and responds to my needs Exceptional
Responds with kindness and respect
Responds with kindness and respect Unacceptable
Responds with kindness and respect Below Average
Responds with kindness and respect Average
Responds with kindness and respect Above Average
Responds with kindness and respect Exceptional
Additional Comments (optional)
2
. POTENTRx Facility
Unacceptable
Below Average
Average
Above Average
Exceptional
Cleanliness
*
POTENTRx Facility Cleanliness Unacceptable
Cleanliness Below Average
Cleanliness Average
Cleanliness Above Average
Cleanliness Exceptional
Aesthetics
Aesthetics Unacceptable
Aesthetics Below Average
Aesthetics Average
Aesthetics Above Average
Aesthetics Exceptional
Parking
Parking Unacceptable
Parking Below Average
Parking Average
Parking Above Average
Parking Exceptional
Accessability
Accessability Unacceptable
Accessability Below Average
Accessability Average
Accessability Above Average
Accessability Exceptional
Location
Location Unacceptable
Location Below Average
Location Average
Location Above Average
Location Exceptional
Additional Comments (optional)
3
. POTENTRx Equipment
Unacceptable
Below Average
Average
Above Average
Exceptional
Cleanliness
*
POTENTRx Equipment Cleanliness Unacceptable
Cleanliness Below Average
Cleanliness Average
Cleanliness Above Average
Cleanliness Exceptional
Comfort
Comfort Unacceptable
Comfort Below Average
Comfort Average
Comfort Above Average
Comfort Exceptional
Quality
Quality Unacceptable
Quality Below Average
Quality Average
Quality Above Average
Quality Exceptional
Reliability
Reliability Unacceptable
Reliability Below Average
Reliability Average
Reliability Above Average
Reliability Exceptional
Accuracy
Accuracy Unacceptable
Accuracy Below Average
Accuracy Average
Accuracy Above Average
Accuracy Exceptional
Additional Comments (optional)
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