Date of Visit:
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Month
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Day
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Year
Age Group:
18 and under
19-29
30-39
40-49
50+
What service did you recieve today?
How would you rate the overall service?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
How would you rate the cleanliness?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
What was the attitude of the staff who attended you?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Did you have to wait for any part of your service?
Yes
No
Was the waiting time acceptable?
Yes
No
Were you dissatisfied with any of the part of the services offered?
Yes
No
Please describe:
Additional comments:
May we contact you?
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