Survey Form

1. Your Name

2. Your Email

3. Are you male or female?

   MaleFemale

4. In what year were you born?

5. What was the main factor that made you decide to come to Davison Audiology?

   LocationReputationRecommendationExisting PatientShort Waiting ListGood EnvironmentFriendly StaffOther (please specify)
   

6. How did you hear about Davison Audiology?

   WebsiteExisting patientBrochureFrom a friendFamily memberNewspaper adDoctor referralOther (please specify)
   

7. What type of appointment did you have?

   Hearing TestHearing Aid FittingFollow upOther (please specify)
   

8. Are you aware of other Davison Audiology locations? (Barnesville, New Martinsville, Glen Dale, St. Clairsville)

   YesNo

9. Were you given a suitable appointment date/time that was acceptable to you?

   YesNo

10. How would you rate the friendliness and helpfulness of staff during your visit?

    Very GoodSatisfactoryPoorDon't Know

11. How would you rate the overall quality of service provided to you during your visit?

    Very GoodSatisfactoryPoorDon't Know

12. Which audiologist did you see today?

    Linda DavisonSuzanne M. Kubancik

13. Did you have confidence and trust in the audiologist treating you?

    YesNo

14. Did the audiologist answer all of your questions regarding the results of your hearing test?

    N/AYesNo

15. Were hearing aids recommended?

    YesNo

16. Were hearing aids purchased?

    N/AYesNo

17. If hearing aids were recommended and not purchased, please explain:

18. After receiving your hearing aid(s), were the instructions clear and concise?

    N/AYesNo

19. Was the staff at Davison Audiology well-informed?

    YesNo

20. How would you rate the overall care you received at this appointment?

    Very GoodSatisfactoryPoorDon't Know

21. Would you recommend Davison Audiology to your family and friends?

    YesNoMaybe

22. Comments

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