* 1. Patient Name

* 2. Who is completing this survey (patient, parent, spouse, etc.)

* 3. Date the patient received lab services

* 4. How did you hear about Summit Pacific Medical Center (newspaper, friend/family, primary care provider, etc.)?

* 5. Would you like to be contacted by administration?  If so, please provide your contact information (phone, email, etc.)

* 6. Overall, how satisfied were you with the lab services you received?

* 7. Would you return to our lab if necessary?

* 8. Is there anyone you would like to recognize for having provided exceptional service during your visit?

* 9. Did you have any concerns regarding the level of care you received during your visit?

* 10. Do you have any suggestions on how we can improve our department?

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