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Customer Satisfaction Survey
Overall, how satisfied are you with our service?
*
1
2
3
4
5
Where did you receive service?
*
Please Select
Clifton Springs Health Center
East DeKalb Health Center
North DeKalb Health Center
Richardson Health Center
T.O. Vinson Health Center
Mobile Outreach Event
Health Fair
Virtual/ School or in Person
Your Home
Your Business
Other
Other Location
What type of service did you receive?
*
Please Select
Clinical Service (Immunization, Family Planning, Medical Records, Travel Medicine, TB, Pregnancy Testing, HIV/STI, PREP/PEP, Health Check, Sports Physical)
Health Assessment and Promotion (Diabetes Prevention, Injury Prevention, Tobacco Use Prevention & Cessation)
Maternal & Child Health (Babies Can't Wait, Children 1st, Children's Medical Services, Early Hearing Detection & Intervention, MORE, WIC, Adolescent Health & Youth Development)
Vital Records (Birth Certificates & Death Certificates)
Environmental Health -Body Art, Hospitality, Lead Poisoning, Mosquito Control, Rodent Control & Septic Systems
Environmental Health -Food Safety
Environmental Health -Public Pools, Beaches & Spas
Immunization Assessment or/and Immunization Training
Oral Health
Other
Other service
How satisfied were you with each of the following:
*
Rows
Not Applicable
Very Dissatisfied
Dissatisfied
Satisfied
Very Satisfied
No Opinion
Friendliness of Staff
Call Center
Check-In Process
Wait Time
Quality of Service
How likely are you to continue to use our services?
*
Very unlikely
Unlikely
Likely
Very likely
No opinion
Do you want to add or suggest something?
Would you be open to a brief follow-up call about your feedback? If so, please provide your contact information.
Please Select
Yes
No
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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