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Sample Re

Questionnaire
Please feel free to complete our feedback questionnaire.
Name:
______________________________________________________________
Address:
______________________________________________________________
Telephone:
______________________________________________________________
Date:
______________________________________________________________
Is this your first visit?
______________________________________________________________
What do you think of our setting and atmosphere?
______________________________________________________________________
In a scale of 0-99%, how would you rate our reception?
________________________________________________________________________
How would you rate our service delivery? (Timely, average, untimely)]
________________________________________________________________________
How did you find the attitude of our staff?

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