Feedback

Is the Feedback?

Praise

Question

Suggestion

Concern

An Incident

Which location is the feedback directed at?

Personal Information

First Name

Last Name

How would you rate us in the following areas?

	Excellent	Very Good	Good	Fair	Poor
Customer Service and Employee Professionalism
Waiting time for service
Facility appearance
Quality of products
Product pricing
Convenience

How often do you visit us?

More than once a week	Once a week	Once every 1-3 weeks	Once a month	Once every 4-6 weeks	Once or twice a year	First visit

Comments

How can we improve?

Would you like a representative to respond to your feedback?

Yes No

Would you like to be on our mailing list for promotional items and coupons?

Yes No