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Customer Satisfaction Assessment Form (Feedback Form)
Your Feedback is Valuable
Name
Date of Visit
Address
Mobile No.
Lab No.
What time did you visit us?
Between 7am-9am
Between 9am-11am
Between 11am-5pm
Between 5pm-9pm
How did you come to know about us?
Referred by Doctor
Friend
Newspaper /Magazine Ad
Hoarding /Kiosk
Leaflet
Close to Home/workplace
If any other, please specify
Why did you choose Medicentre?
Oldest reliable lab
Quality of report
Our services
If any other, please specify
How would you like to collect your report?
Visit the Centre
Through the website
Via E-mail
Home delivery
Are you aware of our home collection and Online report services?
Yes
No
You were aware of any requirement before any test?
Yes
No
How would you rate the courtesy & efficiency of technician?
Excellent
Very Good
Good
Fair
Poor
Would you recommend our services to other?
Yes
No
How would you rate the overall service of the lab?
Excellent
Very Good
Good
Fair
Poor
Was the registration process easy and convenient?
Yes
No
Was the staff at the registration counter courteous?
Yes
No
How long was the waiting time before drawing blood?
0-5 minutes
5-15 minutes
15-30 minutes
More than > 30 minutes
Would you like to give suggestion for our improvement
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