Wellness Center Customer Satisfaction Survey

The Wellness Center seeks to provide excellent care and service. To maintain a high standard of quality service, please help us by answering the following questions. You may do so anonymously but if you'd like a response to your comments you will need to provide contact information. Thank you.

Staff response and action (include name, date, and response)
Name (optional but advised if you would like a response) Name (optional but advised if you would like a response) First Middle Last
Email (optional but advised if you would like a response)
Phone (optional but advised if you would like a response) Phone (optional but advised if you would like a response) - ### - ### ####
Are you a: *

Are you a: Student Faculty Staff Visitor Other Other
Date of visit Date of visit * / MM / DD YYYY
Time of visit Time of visit * : HH MM AM/PM
Type of visit *

Type of visit In office Telephone Email Telehealth Event
Please specify event *
Campus *

Campus Middletown Newburgh Unsure
Reason for contact *

Reason for contact Accident Counseling Crisis Event i.e. Flu Clinic Health Concern Health Professions Physical Immunizations Illness Injury Obtained products i.e. personal hygiene, condoms, , etc. Release of Medical Records Other (please explain) Other (please explain)
Are you satisfied with the care/service you received? *

Are you satisfied with the care/service you received? Yes No Please explain why or why not Please explain why or why not
How could your experience have been better?
What additional services would you like our office to provide?
Thank you for your feedback.

Your feedback is appreciated. If you've asked for a response a member of our team will contact you within the next 24-48 business hours.

Wellness Center Customer Satisfaction Survey

Wellness Center Customer Satisfaction Survey

Thank you for your feedback.