CLIENT SATISFACTION SURVEY
Date Of Your Visit:
Please Indicate How You Would Rate Us Based On A Scale From 1 to 5, Where 5=Excellent And 1=Poor
Professionalism Of Our Staff:
5
4
3
2
1
Cleanliness Of Our Facility:
5
4
3
2
1
Quality Of Services Received:
5
4
3
2
1
Overall Impression Of Our Practice:
5
4
3
2
1
Did You Have To Wait Past Your Scheduled Appointment Time?
Yes
No
If You Answered "Yes" To The Previous Question, Then Please Tell Us How Long You Had To Wait For Your Appointment:
Please Feel Free To Leave Us Any Additonal Comments:
Are our Hours convenient for you?
Yes
No
If not, what hours would be better for you?
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