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Customer Feedback Form

Please comment! We are extremely interested in receiving comments about our services so that we can continually improve them. All input received will be given careful consideration.

What kind of comment would you like to send?

 Suggestion

 Problem

 Praise

1. Were your phone calls handled promptly and politely?

Yes

No

2. Were the staff who worked with you polite and professional?

Yes

No

3. If you had an appointment, were you seen in a timely manner?

Yes

No

4. If you had questions were they answered in a professional manner?

Yes

No

5. Were facilities and equipment used during your visit in good working order?

Yes

No

6. Overall, were you satisfied with our services?

Yes

No

7. Select the reason for your visit or call to the health department

to obtain environmental health permits
to obtain birth or death records
to obtain WIC services
for a clinic visit
to find out about school readiness
to obtain health records

Please tell us what you did or did not like about us in the space provided below:

Please provide the following information if you want us to contact you.

Name:  
E-mail:
Phone:
(Please include Area Code)
   
This page was last modified on: 06/8/2007 10:05:20

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