Client Name :
Address :
City :
State :
Zip :
We would like to have your input to better provide the utmost care with you at the time of examination being done, and future clients
This will increase our awareness on how our examiners have provided you with respect and courteous service.
1. Was our examiner flexible with you in making your appointment?
(Answer yes or no if not please describe)
Yes
No
2. Was the examiner professional and clean?
Rate from 1-2-3-4-5
1. Poor
2. Satisfactory
3. Good
4. Excellent
5. Outstanding
3. Was the examiner ontime and prompt to your needs?
Rate from 1-2-3-4-5
1. Poor
2. Satisfactory
3. Good
4. Excellent
5. Outstanding
4. Did the examiner leave a copy of your lab id #? That you signed.
(Answer yes or no if not please describe)
Yes
No
5. Did the examiner were gloves?
(Answer yes or no if not please describe)
Yes
No
If you have anyone in your family or friends you would recommended to your agent we would be happy to give the agent the names of people you have provided to us below.
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