PATIENT SATISFACTION SURVEY
To better meet the needs of our customers, we ask you to take a few minutes and complete the survey.
Date and Time:
Phone Number:
1. How long did you wait in the waiting room?
2. Was our receptionist courteous?
Yes
No
3. Did the waiting room appear clean and tidy?
Yes
No
4. Was an introduction provided by the phlebotomist?
Yes
No
5. Did the phlebotomist ask you to state your name?
Yes
No
6. Did the phlebotomist ask you to state your date of birth?
Yes
No
7. Was the phlebotomist courteous?
Yes
No
8. Was the phlebotomist professional in appearance?
Yes
No
9. Did the drawing area appear clean and tidy?
Yes
No
10. Would you recommend our services to others?
Yes
No
Please rate your overall experience today by circling one of the choices below.
*
Rows
1 Poor
2 Fair
3 Average
4 Good
5 Excellent
Select
Additional Comments/Suggestions:
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