PGM S.R.L.

Sede Amministrativa e Studi Professionali

Via Santo Stefano 103

40125 Bologna

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Tel. E Fax ++ 39 051 4842736 Direttore Sanitario: Dr. Missere Maurilio

Email segreteria@fondazionectr.it

EVALUATION QUESTIONNAIRE

Help us to improve our service by filling out the form ANONYMOUSLY

1. How did you know our clinic?O Facebook O Instagam O Internet O Word of Mouth O Other _____________

2. Did you find our clinic hardly?O Yes O No

3. What were your waiting times to receive an appointement at our clinic?O Less than 5 days O From 5 to 10 days O Over 10 days

4. Has the Doctor been available with you?O Yes, he/she was very available and helpful O Yes, he/she was available but I woul have expected more O No, he/she was not

5. How was the availability and courtesy of the secretarial staff of our clinic?O Inadequate O Good O Excellent

6. Form which doctor have you benn visited at our clinic?_________________________________________________________________________________

7. Have you been visited by other doctors at our clinic? If so, by whom?_________________________________________________________________________________

8. Do you know the other services offered by our clinic? If so, from what source? (at the clinic, from internet, facebook, Instagram, word of mouth, exc)?_________________________________________________________________________________

9. Have you ever received our newsletter by e-mail?O Yes O No

10. Would you like to receive our initietives and promotions by e-mail? If so, write your e-mail address below._________________________________________________________________________________

11. Have you ever used our promotions? If so, what promotion did you use?_________________________________________________________________________________

12. Do you have any suggestions to advise us?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Do you suggest amissing service that you would like to use?___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you for your cooperation.

PGM S.R.L.

Sede legale Via Dè Butteri 8 – 40125 Bologna

www.poliambulatoriogiardinimargherita.it

P.IVA e C.F. 03412871208 Capitale Sociale 10.000,00