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? *
Very Dissatisfied
Very Satisfied
Please tell us how you would improve the experience. *
How would you rate the care you received today? *
Very Dissatisfied
Very Satisfied
Please explain. *
How did you hear about the clinic? *
Which expanded hours would you like to see? (Check all that apply)
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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