Schiffert Health Center Feedback Form

Please let us know about your experience at the Schiffert Health Center

Question 1

Which areas did you visit? (choose all that apply)

Indicate your satisfaction

	1 - Totally dissatisfied	2	3	4	5 - Totally satisfied
	1	2	3	4	5
Rate your visit

Please leave your comments or suggestions regarding your visit to the Health Center

Choose one

I would like to remain anonymous.
I would like to leave my contact information so that Schiffer Health Center staff can reach out to me to respond to any concerns I indicated on this form.

If you chose to be contacted, please enter the name you used to check-in at the health center, and a phone number