Customer Survey Form...

* required information

If you are willing and have a couple of minutes, we would greatly appreciate your efforts in completing this survey. As those of you who have allowed us to serve you know, one of our goals is to provide you with services in a friendly, personal, and professional manner. By completing this survey you will allow us to improve upon what we are here to do serve you and improve your health. In advance, thanks much for taking time out of your busy day.

Are you a new patient/customer to the Clinic Pharmacy of West Salem?
Yes
No

How did you originally hear about the Clinic Pharmacy of West Salem?

Are you a current patient/customer to the Clinic Pharmacy of West Salem?
Yes
No

If Yes, for how long?

What is your reason for being here today?

Please inform us of any positive experience(s) you have had with us.

Please inform us of any negative experience(s) you have had with us.

How can we improve our service?

What services/products do we not presently provide that you wish we did?

Do you have access to the internet?
Yes
No

If Yes, in accessing our Web page (www.ClinicPharmacyofWestSalem.com) would you be interested in purchasing Gift/Home Décor items from our Web site?
Yes
No

If you have access to the internet, what would you like to see included on our Web site?

If the Clinic Pharmacy of West Salem were to close for a 30-minute lunch, would this inconvenience you?
Yes
No

If No, what 30-minute time frame for closing would best fit for not inconveniencing you?

Optional:
You may wish a reply or response of some kind. If so, please include your name/phone number/e-mail address below.
Name:

Address:

City:

State:

Zip:

* E-mail:

* Please key in the access code above for verification.

Thank you for taking the few minutes to complete this survey. One of our goals is to provide the best possible services, the services you desire and deserve. This survey will help us to achieve that goal. Thanks again.

George Christiansen