* 1. Today's Date

* 2. What services did you have today?

* 3. Please rate the following:

  Excellent Satisfactory Unsatisfactory
Staff answered my questions
Courtesy of staff
Quality of staff
Promptness of service
Overall satisfaction

* 4. How can we improve our services?

* 5. Do you have something that you would like to discuss with us?

* 6. Would you like to recognize a staff person for exceptional service?