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* 1. Site Location:

* 2. Name

* 3. Please rate our Patient Care Center based on today's visit.

  Excellent Good Average Fair Poor
Respect shown for your privacy.
Time you waited for collection.
Professionalism of our staff.
Cleanliness of our facility.

* 4. Additional questions:

  Yes No
Did we anticipate and satisfy your needs?
Did we greet you in a warm and friendly manner?
Our goal is to put the patient first in everything we do. Did we meet that goal?

* 5. Return visit?

  Yes Probably Maybe Probably Not No
Will you return to our facility for testing?

* 6. Who is your insurance with?

* 7. Comments:

T