Home Visit Survey

To ensure that you are satisfied with the service we provide, we are requesting your feedback.

Your input is greatly appreciated and will be utilized to help us improve your experience with Northwell Health Labs Mobile Services.

Click the appropriate number from 1 "Very Dissatisfied" to 5 "Very Satisfied".
	1	2	3	4	5
Was the call you received the evening before the visit informative?
Were you satisfied that the technician arrived as scheduled?
Was the technician courteous, professional and polite?
Did the technician provide proper/complete identification?
Was the technician thorough in verifying your full name and date of birth?
Did the technician wash or sanitize their hands before putting on gloves?
How skillful was the technician in obtaining the blood specimen?
Was the technician well organized and able to perform their function promptly?
Were you satisfied with the post care blood draw instructions?
How would you rate the overall experience with the technician?

Please include any additional comments/suggestions regarding our service
Patient Name (optional)
Technician's Name (optional)
Date of Service (MM/DD/YYYY)
	Check this box if you want your response to remain confidential.
	Check this box if you would like us to contact you and include your phone number below.
Phone# (XXX-XXX-XXXX)
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