Client Satisfaction Survey
Date:
Clinic Location:
Name:
Address:
City:
State:
Zip:
Phone:
Fax:
Employer Name:
Your Title:
Your Email:
No. of Employees:
Employer Primary Contact:
Primary Contact No:
Employer Secondary Contact:
Secondary Contact No:
Drug screen results received within 24-72 hours?:
Yes No
Drug screen and physical reporting done in a timely manner?:
Yes No
Work status notes & referrals reported same day?:
Yes No
Bills received timely, accurate and legible?:
Yes No
Clinic appointment availability:
Excellent Good Average Poor
Was the staff courteous, polite and professional?:
Excellent Good Average Poor
Cleanliness & comfort of clinic:
Excellent Good Average Poor
Overall quality of client care:
Excellent Good Average Poor
Would you recommend another employer to ACMG?:
Yes No
Do you utilize the 24/7 Riverwalk Urgent Care Clinic?:
Yes No
Are you familiar with our onsite services?:
Yes No
Which clinic do you prefer sending your employee to?:
Would you consider our clinic for any future medical services? If Yes please select an answer from the drop down box:
Please make recommendations you would like to see to better serve you?
Comments:

 

 

 

 

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