Customer Satisfaction SurveyCustomer Satisfaction Survey

*

1. What age group does the patientfall into and when was your most recent appointment with us?

	Age Group	Last Appointment Date
Please select one of each	What age group does the patientfall into and when was your most recent appointment with us? Please select one of each Age Group	Last Appointment Date

2. Please let us know how you perceive your reception at the Clarke Hearing Center in terms of:

	Excellent	Good	Adequate	Needs Improvement	Poor	N/A
Friendliness of staff	*Please let us know how you perceive your reception at the Clarke Hearing Center in terms of: Friendliness of staff Excellent	Friendliness of staff Good	Friendliness of staff Adequate	Friendliness of staff Needs Improvement	Friendliness of staff Poor	Friendliness of staff N/A
Ability to answer your questions	Ability to answer your questions Excellent	Ability to answer your questions Good	Ability to answer your questions Adequate	Ability to answer your questions Needs Improvement	Ability to answer your questions Poor	Ability to answer your questions N/A
Time it took to check in/out	Time it took to check in/out Excellent	Time it took to check in/out Good	Time it took to check in/out Adequate	Time it took to check in/out Needs Improvement	Time it took to check in/out Poor	Time it took to check in/out N/A
Ease of getting us via phone	Ease of getting us via phone Excellent	Ease of getting us via phone Good	Ease of getting us via phone Adequate	Ease of getting us via phone Needs Improvement	Ease of getting us via phone Poor	Ease of getting us via phone N/A
Ease of scheduling an appointment	Ease of scheduling an appointment Excellent	Ease of scheduling an appointment Good	Ease of scheduling an appointment Adequate	Ease of scheduling an appointment Needs Improvement	Ease of scheduling an appointment Poor	Ease of scheduling an appointment N/A
Location and parking	Location and parking Excellent	Location and parking Good	Location and parking Adequate	Location and parking Needs Improvement	Location and parking Poor	Location and parking N/A
Waiting room	Waiting room Excellent	Waiting room Good	Waiting room Adequate	Waiting room Needs Improvement	Waiting room Poor	Waiting room N/A

Additional comments:

3. Please let us know how you perceive your audiological appointment at the Clarke Hearing Center in terms of:

	Excellent	Good	Adequate	Needs Improvement	Poor	N/A
Competency of audiologist	*Please let us know how you perceive your audiological appointment at the Clarke Hearing Center in terms of: Competency of audiologist Excellent	Competency of audiologist Good	Competency of audiologist Adequate	Competency of audiologist Needs Improvement	Competency of audiologist Poor	Competency of audiologist N/A
Attentiveness to your problems and concerns	Attentiveness to your problems and concerns Excellent	Attentiveness to your problems and concerns Good	Attentiveness to your problems and concerns Adequate	Attentiveness to your problems and concerns Needs Improvement	Attentiveness to your problems and concerns Poor	Attentiveness to your problems and concerns N/A
The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options.	The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options. Excellent	The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options. Good	The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options. Adequate	The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options. Needs Improvement	The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options. Poor	The clarity of the doctor's explanation of your hearing loss, impact on communication, and treatment options. N/A

Additional comments:

4. Overall, how do you rate the quality of the services you received?

Overall, how do you rate the quality of the services you received? Excellent

Good

Adequate

Needs Improvement

Poor

5. Did knowing that Clarke Hearing Center is a non-profit clinic which helps support programs and services for children with hearing loss and their families in your community and beyond have any impact on your decision to become a patient here?

Did knowing that Clarke Hearing Center is a non-profit clinic which helps support programs and services for children with hearing loss and their families in your community and beyond have any impact on your decision to become a patient here? Yes

It was a consideration

No

I had no idea of the relationship

6. Based on our performance, how likely is it that you will use us in the future?

Based on our performance, how likely is it that you will use us in the future? Certain

Very likely

Somewhat likely

Unlikely

Very unlikely

7. Would you recommend us to a friend?

Would you recommend us to a friend? Yes

No

8. If you have any suggestions regarding how we could improve the services we provide to you, please enter them in the box below.

If you have any suggestions regarding how we could improve the services we provide to you, please enter them in the box below.

9. If you would like to share a testimonial with us that we may use in marketing materials, please print and sign your name and best way to contact you below:

If you would like to share a testimonial with us that we may use in marketing materials, please print and sign your name and best way to contact you below: Name:
Address:
City/Town:
State:
ZIP:
Country:
Email Address:
Phone Number:

10. If you would like someone to contact you regarding your visit or unresolved problem, please print your name and best way to contact you below:

If you would like someone to contact you regarding your visit or unresolved problem, please print your name and best way to contact you below: Name:
Email Address:
Phone Number:

Customer Satisfaction Survey
Cancel this survey >>

How Are We Doing?

Customer Satisfaction SurveyCancel this survey >>

How Are We Doing?

Customer Satisfaction Survey
Cancel this survey >>