Customer Service Survey

Question Title

* 1. Was requesting an appointment convenient?

Yes

No

Question Title

* 2. Upon arrival, how long was the wait between your appointment time and seeing the provider?

0 – 15 minutes

15 – 30 minutes

More than 30 minutes

Question Title

* 3. Were you treated kindly by the front office staff?

Yes

No

Question Title

* 4. Were you greeted by the staff and were you offered assistance?

Yes

No

Question Title

* 5. Did the provider listen to you and answer all of your questions?

Yes

No

Somewhat

Question Title

* 6. Did you understand the information given to you?

Yes

No

Question Title

* 7. Were you given privacy when seeing the provider?

Yes

No

Question Title

* 8. Was the facility clean?

Yes

No

Question Title

* 9. Would you suggest this clinic to family and friends?

Yes

No

Question Title

* 10. What suggestions do you have to improve your experience for the next visit?

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________