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Creative Images Customer Survey

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* 1. What services did you receive?

Mastectomy Bras

Breast Prosthesis

Compression Garments

Wigs/Hair Replacement

All of the Above

Other (please specify)

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* 2. Did you have a scheduled appointment?

Yes

No

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* 3. Is this facility your sole provider for this type of medical care?

Yes

No

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* 4. How did you hear about our services?

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* 5. Please respond to how you agree with the following statements:

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree	N/A
When you called the facility, the person who answered the phone was prompt.	When you called the facility, the person who answered the phone was prompt. Strongly Disagree	When you called the facility, the person who answered the phone was prompt. Disagree	When you called the facility, the person who answered the phone was prompt. Neutral	When you called the facility, the person who answered the phone was prompt. Agree	When you called the facility, the person who answered the phone was prompt. Strongly Agree	When you called the facility, the person who answered the phone was prompt. N/A
Your check in process was efficient.	Your check in process was efficient. Strongly Disagree	Your check in process was efficient. Disagree	Your check in process was efficient. Neutral	Your check in process was efficient. Agree	Your check in process was efficient. Strongly Agree	Your check in process was efficient. N/A
The facility staff was friendly to you.	The facility staff was friendly to you. Strongly Disagree	The facility staff was friendly to you. Disagree	The facility staff was friendly to you. Neutral	The facility staff was friendly to you. Agree	The facility staff was friendly to you. Strongly Agree	The facility staff was friendly to you. N/A
All of your questions/concerns were answered by your Practitioner.	All of your questions/concerns were answered by your Practitioner. Strongly Disagree	All of your questions/concerns were answered by your Practitioner. Disagree	All of your questions/concerns were answered by your Practitioner. Neutral	All of your questions/concerns were answered by your Practitioner. Agree	All of your questions/concerns were answered by your Practitioner. Strongly Agree	All of your questions/concerns were answered by your Practitioner. N/A
Overall, you were satisfied with your experience at the facility.	Overall, you were satisfied with your experience at the facility. Strongly Disagree	Overall, you were satisfied with your experience at the facility. Disagree	Overall, you were satisfied with your experience at the facility. Neutral	Overall, you were satisfied with your experience at the facility. Agree	Overall, you were satisfied with your experience at the facility. Strongly Agree	Overall, you were satisfied with your experience at the facility. N/A
Your wait time for the services you received was reasonable?	Your wait time for the services you received was reasonable? Strongly Disagree	Your wait time for the services you received was reasonable? Disagree	Your wait time for the services you received was reasonable? Neutral	Your wait time for the services you received was reasonable? Agree	Your wait time for the services you received was reasonable? Strongly Agree	Your wait time for the services you received was reasonable? N/A

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* 6. Where you satisfied with the products and services provided?

Yes

No

Comment:

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* 7. Please use the space below to add any comments you may have.