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* 1. Which service did you receive today?

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* 2. What was the purpose of the visit?

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* 3. Time and date of visit/service:

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* 4. Name of staff member:

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* 5. On a scale of 1 to 5, 1 being untrue and 5 being very true, please let us know if staff were:

  1 2 3 4 5
Helpful
Knowledgeable
Courteous

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* 6. On a scale of 1 to 5, 1 being untrue and 5 being very true, please let us know if the service was:

  1 2 3 4 5
Helpful
Provided in a fair and consistent manner

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* 7. Overall, did the service you receive:

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* 8. What would you suggest to improve our service?

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* 9. Did any member of our staff provide exceptional service? If yes, please provide name and details.

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* 10. If you would like a response to your comments, please complete the following (optional):

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