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Customer Service Survey


Please fill out the following survey and press submit when finished.



* Indicates required information
Title * 




First Name * 
Last Name * 
Email Address * 
Phone Number 
Street Address 
City 
State 
Zip 
Date of your most recent visit 
Where did you receive care? 





If yes please specify which clinic 
How effective were the management and staff in the following areas? Did they... 
1. Treat you in a friendly and professional manner that made you and members of  * 
2. Go beyond your expectations in terms of the customer service they provided? * 
3. Show a real sense of urgency and fulfill your request promptly? * 
4. Seem well-organized and systematic in carrying out their work? * 
5. "Get it right the first time" by paying attention to important details? * 
6. Keep their promises? Can you rely on them to follow up on your requests? * 
7. Overall how would you rate the level of customer service your received? * 
8. How would you compare our standards of customer service with other health car * 
9. Would you use this health system again and/or recommend it to someone else? * 
Additional Information: including the name of individuals you would like recommended for recognition