Customer Feedback Form
Dear Customer, At Leeuwenhoek we very much value your opinion. Therefore, we would like to ask you to take some time to complete this form. Your feedback allows us to continue to improve our services so to best meet your needs and expectations. Thank you for taking your time! Leeuwenhoek Management
Overall, how would you rate Leeuwenhoek’s service?
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1
2
3
4
5
Poor
Excellent
1 is Poor, 5 is Excellent
The Visit
How would you rate Leeuwenhoek's visit?
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Rows
Strongly agree
Agree
Unsure
Disabree
Strongly disagree
Booking was easy
The reception area is clean and adequate
The phlebotomy (blood drawing) area is clean and adequate
The screening is accessible (e.g. lenient eligibility criteria, short waiting times)
The staff are friendly
The Report and aftercare
How would you rate the report of your results and aftercare?
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Rows
Strongly agree
Agree
Unsure
Disabree
Strongly disagree
Leeuwenhoek performed a thorough analysis of my samples
The report answered my questions
I received the report on time
The report was complete and easy to understand
The staff answered my questions and clarified any questions regarding my results
The Experience
How would you rate the experience?
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Rows
Strongly agree
Agree
Unsure
Disabree
Strongly disagree
Leeuwenhoek has increased my understanding of my health status
Leeuwenhoek allows me to be proactive in mywellbeing
Leeuwenhoek’s service meets/ exceeds my expectations
I would like to use Leeuwenhoek’s service in thefuture
I would recommend Leeuwenhoek to a friend
Please provide any comments or suggestions about the service you received
Can we use your feedback including your first & last name as a testimonial on our website (“What our customers say about us”)?
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Yes
No
Optional: Contact Details
Your Name
First Name
Last Name
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