WHS Customer Feedback Survey

Date of Service(s)

Time of Service(s)

Name (optional)

Email (optional)

Check ALL Services Used During This Visit

Allergy Injections

Athletic Training

Business Office

Check-in

Faculty & Staff Clinic

General Medicine

Laboratory

Nursing

Pharmacy

Radiology (x-ray)

Walk-in Clinic

Women's/Men's Health

How satisfied were you with your visit today?

Very Satisfied

Satisfied

Neutral

Unsatisfied

Very Unsatisfied

How can we improve your future visits?

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