St. Luke's Medical Center Extension Clinic

Service Evaluation Form

Please rate our services by selecting the circle that best describes your over-all experience at each area.

Please do not leave required (*) fields empty.

I visited the SLEC branch in *

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I am applying for a visa to *

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Service Area: *

Which area or staff do you think did a good job? *

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Which area or staff do you think needs improvement? *

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Date of Visit *

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Name of Respondent (Optional)

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