Advanced Weight Loss Clinics

Visit Feed Back

Please take the time to tell us about your experience in our clinics. This helps us improve our customer service and may help us in areas where we can be more accommodating to our patients.

If you have any questions please do not hesitate to call the appointment line at 205-670-5355 or 1-877-Lets-Lose.

Which clinic did you visit?: *

Date of Visit: *

Time of Visit: *

:

am

pm

Was this your first visit to one of our weight loss clinics?:

Yes

No

Approximately how long did you have to wait in the lobby?:

No Wait

< 5 minutes

5 to 10 minutes

> 10 minutes

Please Rate the Following:

Please rate the following on a scale from Poor to Excellent. If the question does not apply to your visit, either leave it blank or select Not Applicable.

Rate the Following:

	Excellent	Very Good	Good	Fair	Poor	N/A
the atmosphere and cleanliness of the clinic?
the clinical staff?
the doctor?
the staff's ability to answer your questions?
your overall visit

Comment::

If there is anything you else you would like to tell us, or if you would like to clarify your choices above, please use this text box.

Personal Information

If you had a specific issue you feel needs to be addressed, please provide your name and email. This step is entirely optional. You do not need to provide this information to submit this form.

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email:

Advanced Weight Loss Clinics

Weight loss made simple!

Visit Feed Back