New Customer Feedback Form - Total Scope, Inc.

Name*
First Last
Phone*
Phone Extension
Hospital*
Department*
Email*
Medical Device Model*
Work Order #*
Our ability to repair your medical device?*
The reliability or accuracy of our estimate?*
The professionalism and courtesy of our staff?*
Our turnaround time?*
How quickly & smoothly the process went for getting your equipment sent to us?*
Likelihood that you will use Total Scope again?*
Would you refer Total Scope to another department or facility?*
- Yes
- No
- Yes, but I don't have a referral at this time
Receive 25% OFF your next repair if you provide us with the name of the referral, Facility Name and Phone Number and receive 50% OFF if you also provide us with the Department name and Contact Email. *The contact you refer must use our services to receive your discount.
Name of Person You Are Referring Us To
First Last
Facility Name
Contact Phone
Department Name
Contact Email
Would you like to be contacted about this repair?*
Is there anything we can do to improve your medical device repair experience?*
Would you like to serve as a reference for customers interested in using Total Scope? If so, please tell us what you liked about our services.*
Receive Emails*