Medical Receptionist Feedback Form
Please share your feedback about your recent experience with our medical receptionist. Your responses help us improve our service.
Date of your visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which receptionist assisted you?
*
Please Select
Receptionist 1
Receptionist 2
Receptionist 3
Not sure/Don't remember
How would you rate the professionalism of the receptionist?
*
1
2
3
4
5
How clearly did the receptionist communicate with you?
*
1
2
3
4
5
How long did you wait before being assisted?
*
Please Select
Less than 5 minutes
5-10 minutes
10-20 minutes
More than 20 minutes
Please share any additional comments or suggestions for improvement
May we contact you for follow-up regarding your feedback?
*
Yes, you may contact me
No, I prefer to remain anonymous
Your email address (if you wish to be contacted)
example@example.com
Submit Feedback
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