sample customer feedback form for laboratory services

Laboratory Services Quality Assurance and Feedback Survey

Instructions for Use

• Complete all sections relevant to the specific testing services provided to ensure our Quality Management System can effectively address your feedback.
• Submit the completed form via the designated quality department email address or secure portal provided in your service agreement.
• All submissions are treated as confidential records and will be reviewed by our Laboratory Director to facilitate continuous improvement and corrective action processes.

Parties and Definitions

This form is submitted by [Client Name/Organization] ("Client") to [Laboratory Company Name] ("Laboratory") regarding testing services performed under Account Number [__________].

Date of Service: [] Laboratory Report/Accession Number(s): []

Operative Clauses

1. Service Scope and Quality Assessment Please rate your satisfaction with the following aspects of the laboratory services provided (1 = Poor, 5 = Excellent):

• Timeliness of Reporting: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5
• Accuracy of Results: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5
• Clarity of Documentation: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5
• Professionalism of Staff: [ ] 1 [ ] 2 [ ] 3 [ ] 4 [ ] 5

2. Technical and Operational Feedback Describe any specific observations regarding the testing methodology, sample handling, or reporting procedures: [__________]

3. Corrective Action Request Does this feedback constitute a request for a formal investigation or re-testing?

• Yes
• No If yes, please specify the nature of the discrepancy: [__________]

4. Confidentiality and Data Protection The Laboratory acknowledges that any feedback provided herein may contain sensitive data. The Laboratory agrees to process this information in accordance with applicable data privacy regulations, including [Specify Relevant Regulation, e.g., HIPAA/GDPR/ISO 15189].

5. Resolution Process The Laboratory commits to acknowledging receipt of this feedback within [] business days and providing a preliminary status update regarding any requested corrective actions within [] business days.

Signature and Acknowledgment

By signing below, the representative confirms that the information provided is accurate to the best of their knowledge and authorizes the Laboratory to use this data for internal quality improvement purposes.

Signature: __________ Printed Name: [] Title: [] Date: [__________]

Legal Disclaimer: This document serves as a general template and does not constitute legal advice. Laboratory operations are subject to specific regulatory requirements (e.g., CLIA, CAP, ISO). Consult with qualified legal counsel to ensure compliance with jurisdiction-specific laws and accreditation standards.