Patient Satisfaction Survey *: Required Field Name of Patient * Date of Visit Cleanliness of Facility 1 - Very Poor 2 - Poor 3 - Fair 4 - Good 5 - Very Good Location Select... Beavercreek Beavercreek - Fam Phys Bldg Centerville - Miami Valley Hospital South Campus Centerville - SouthMed Medical Bldg Dayton - Brown Street Dayton - Elizabeth Place Dayton - Miami Valley Hospital Dayton - Miami Valley Hospital Dayton - Wyoming Englewood Fairborn Huber Heights Kettering Kettering - Park Place Lebanon Lebanon - Union Village - near Otterbein Liberty Township Mason - Premier Urgent Care Miamisburg - Premier Health Urgent Care Middletown Middletown - Atrium Medical Center Moraine Oxford Piqua Springboro Springfield Derr Road Springfield North Springfield Ohio Valley Surgical Center Springfield South Tipp City Troy Troy - Dorset Road Troy - Upper Valley Medical Center Urbana Vandalia Versailles West Chester Wright State Univ. - Physicians Bldg Xenia Was staff courteous and polite? 1 - Very Poor 2 - Poor 3 - Fair 4 - Good 5 - Very Good Name of Phlebotomist (staff member drawing your blood) Skill of phlebotomist collecting specimen 1 - Very Poor 2 - Poor 3 - Fair 4 - Good 5 - Very Good What was the overall level of care you received during your visit? 1 - Very Poor 2 - Poor 3 - Fair 4 - Good 5 - Very Good How would you rate the length of your wait time? Would you recommend CompuNet Clinical Laboratories to a family member or friend? No Yes Would you like a return call concerning your visit? No Yes Contact Name (if other than patient) Would you like to share a testimonial about how lab testing has improved your life? No Yes Phone (only provide if you wish to receive a return call) Comments or Suggestions
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