Customer Feedback Survey

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* 1. Contact Information

Name

Hospital

Email Address

Phone Number

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* 2. Date

Date / Time

Date

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* 3. Using the scale below, please rate the following

	Poor	Fair	Average	Good	Excellent
The equipment and/or supplies arrived at the agreed upon time.	The equipment and/or supplies arrived at the agreed upon time. Poor	The equipment and/or supplies arrived at the agreed upon time. Fair	The equipment and/or supplies arrived at the agreed upon time. Average	The equipment and/or supplies arrived at the agreed upon time. Good	The equipment and/or supplies arrived at the agreed upon time. Excellent
Adequate instructions were provided for the safe use of the equipment.	Adequate instructions were provided for the safe use of the equipment. Poor	Adequate instructions were provided for the safe use of the equipment. Fair	Adequate instructions were provided for the safe use of the equipment. Average	Adequate instructions were provided for the safe use of the equipment. Good	Adequate instructions were provided for the safe use of the equipment. Excellent
Our staff were courteous and helpful.	Our staff were courteous and helpful. Poor	Our staff were courteous and helpful. Fair	Our staff were courteous and helpful. Average	Our staff were courteous and helpful. Good	Our staff were courteous and helpful. Excellent
Overall customer satisfaction rating.	Overall customer satisfaction rating. Poor	Overall customer satisfaction rating. Fair	Overall customer satisfaction rating. Average	Overall customer satisfaction rating. Good	Overall customer satisfaction rating. Excellent
Overall satisfaction with our product.	Overall satisfaction with our product. Poor	Overall satisfaction with our product. Fair	Overall satisfaction with our product. Average	Overall satisfaction with our product. Good	Overall satisfaction with our product. Excellent
Product quality.	Product quality. Poor	Product quality. Fair	Product quality. Average	Product quality. Good	Product quality. Excellent
Customer service.	Customer service. Poor	Customer service. Fair	Customer service. Average	Customer service. Good	Customer service. Excellent

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* 4. How knowledgeable did our customer service representative seem to you?

Extremely knowledgeable

Very knowledgeable

Moderately knowledgeable

Slightly knowledgeable

Not at all knowledgeable

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* 5. How clear was the information that our customer service representative provided to you?

Extremely clear

Very clear

Moderately clear

Slightly clear

Not at all clear

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* 6. Were you satisfied with your last experience with our company, neither satisfied nor dissatisfied with it, or dissatisfied with it?

Extremely satisfied

Moderately satisfied

Slightly satisfied

Neither satisfied nor dissatisfied

Slightly dissatisfied

Moderately dissatisfied

Extremely dissatisfied

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* 7. How well did our customer service representative answer your question or solve your problem?

Extremely well

Very well

Moderately well

Slightly well

Not at all well

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* 8. Do you know who your local sales representative is?

Yes

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* 9. Do you have your reps contact details?

Yes

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* 1. Contact Information

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* 2. Date

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* 3. Using the scale below, please rate the following

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* 4. How knowledgeable did our customer service representative seem to you?

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* 5. How clear was the information that our customer service representative provided to you?

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* 6. Were you satisfied with your last experience with our company, neither satisfied nor dissatisfied with it, or dissatisfied with it?

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* 7. How well did our customer service representative answer your question or solve your problem?

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* 8. Do you know who your local sales representative is?

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* 9. Do you have your reps contact details?

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* 10. Do you have any other comments, questions or concerns?