ICNA Relief's SHAMS Clinic Patient Satisfaction Survey
Peace be upon you. Please tell us about your visit today and help us improve our quality of care. All feedback will be kept anonymous.
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What brought you to visit the clinic?
Overall, were you satisfied or dissatisfied with your experience at SHAMS Clinic?
Please tell us how you would improve the experience.
How would you rate the care you received today?
How did you hear about the clinic?
Referral from a hospital or doctor office (Please specify in below)
Non-profit organization (please specify below)
Social Media (facebook, internet., ect)
Local community (i.e. mosque, church etc)
Which expanded hours would you like to see? (Check all that apply)
Weekday (Mon-Thurs) evening
Weekday (Mon-Thurs) morning
Weekend (Fri-Sun) afternoon
Would you like to share a testimonial about your experience? Just provide us your contact information and we will contact you.
Contact Information (Optional) Name
Contact Information (Optional) Phone Number
Contact Information (Optional) Email Address
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