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Customer Feedback Form
Compliment Complaint Suggestion
Your contact information is optional. However, it allows us to contact you for follow-up and/or feedback purposes.
Name:
Phone Number:			Date of visit:
E-mail:
Service provided to:		General scope of treatment:
Approximate length of visit: Time you waited:
Physician or Department visited:
Were you treated	Courteously?	Yes No
	Timely?	Yes No
	Professionally?	Yes No
Was your appointment scheduled to your satisfaction? Yes No
Your comments regarding clinic services are welcome:

Bend Memorial Clinic, PC

1501 NE Medical Center Drive - Bend, OR 97701
Main Number: 541-382-2811 or 866-670-2811 - Appointments: 541-382-4900 or 866-553-4900