Client Satisfaction Survey Welcome to the VBCDHD’s client satisfaction survey. This form may take less than 5 minutes to complete. Client satisfaction is our goal and your input is important to us. Please take a moment to answer the questions below.Date of Service MM slash DD slash YYYY How did you hear about us? Were you happy with the overall service you received? Yes No Please grade this service(0 to 5 with 0 being the worst and 5 being the best) 0 1 2 3 4 5 At what site did you receive service? Lawrence Dowagiac Other How would you rate the cleanliness of this facility?(0 to 5 with 0 being the worst and 5 being the best) 0 1 2 3 4 5 Was staff helpful and courteous? Yes No Did you find the cost of the services reasonable? Yes No Did you have a scheduled appointment or were you a walk-in? Scheduled appointment Walk-in Other Which Department did you see? Dental EH - Food Service EH - Septic/Sewage and/or Well/Water Services Nursing - CSHCS Nursing - Immunizations/Tb testing, etc. Administrative / Finance / Accounting / Billing Other Did you have to wait more than 15 minutes before being seen? Yes No Was personal health information dealt with in a confidential manner? Yes No If No, please explain Did your visit, in some way, help your ability to obtain employment? Yes No If Yes, please explain Were the services you received explained to you in a manner you understood? Yes No If No, please explain Did we meet your needs? Yes No If No, please explain How can we improve our services?Would you like us to contact you to discuss your concerns? Yes No About youHow can we contact you?Name First Last PhoneEmail CommentsThis field is for validation purposes and should be left unchanged.
