Customer Satisfaction Survey Question Title * 1. How likely is it that you would recommend this clinic to a friend or colleague? NOT AT ALL LIKELY EXTREMELY LIKELY 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 OK Question Title * 2. Overall, how satisfied or dissatisfied are you with this clinic?? Very satisfied Somewhat satisfied Neither satisfied nor dissatisfied Somewhat dissatisfied Very dissatisfied OK Question Title * 3. Which of the following words would you use to describe this clinic ? Select all that apply. Reliable High quality Useful Unique Concerns were addressed Impractical Ineffective Poor quality Unreliable OK Question Title * 4. How well does the clinic meet your needs? Extremely well Very well Somewhat well Not so well Not at all well OK Question Title * 5. How long have you been a patient of the clinic? This is my first visit Less than six months Six months to a year 1 - 2 years 3 or more years I haven't had a visit OK Question Title * 6. How well were your needs met during your last appointment? They were met Not met Exceeded expectations OK Question Title * 7. Do you have access to a smart phone and a private wifi connection? Yes No OK Question Title * 8. Do you have a laptop or desktop computer with a webcam and online access? Yes No OK Question Title * 9. How interested are you in online video appointments? Extremely interested Very interested Somewhat interested Not so interested Not at all interested OK Question Title * 10. What is your contact information? Name Address City/Town State/Province ZIP/Postal Code Email Address Phone Number OK DONE