Customer Survey

Customer Feedback Form

Why are you contacting us:

Compliment Dissatisfied Suggestion

(Include your contact information if you would like to hear from us.)

First Name: Last Name:

Phone Number: Email:

(If this is regarding a visit to the clinic, let us know how we did.)

Who were the services for :

Why did you visit the clinic:

How much time spent waiting:

Time spent with your provider:

Provider or department visited:

(Describe your overall experience while at the clinic.)

The staff treated me professionally:	Yes No
The staff treated me courteously:	Yes No
I was seen in a timely manner:	Yes No

Use the text box below to add any additonal comments.