Customer Satisfaction Survey

Gereral Information

Name (Optional):

Phone (Optional):

E-Mail (Optional):

Date of visit (Required):

Time of visit (Optional):

Physician seen (Optional):

Location visited (Required):

Who is filling out this survey? (Required):

Please rate the following (Required):

Please answer "yes" or "no" to the following (Required):

	Yes	No
Was this your first visit to StatClinix?
Would you return to StatClinix again?
Would you recommend StatClinix to family and friends?

How did you hear about StatClinix? (Optional):

Additional Comments (Optional):

	Poor	Fair	Good	Great
Convenience of StatClinix location
Convenience of StatClinix hours
Quality of the reception staff
Time taken to get into an exam room
Time taken to see a Physician
Quality of the Physician you saw
Thoroughness of the Physician you saw
Explanation of treatment
Explanation of personal and follow-up care
Overall quality