Dear

I have been pleased to work with you and hope you feel the same.  
I always hope to improve my service to my patients, and one way I accomplish that is by asking for feedback from the patients or caregivers I assist.  That’s the purpose of this letter.
Would you help me improve my service by filling out this form?  You can write on this paper, use the back, add sheets of paper – whatever works for you.  
Please return it within 10 days so our work together will still be fresh in your mind.  
Good health to you.  Please feel free to call on me in the future should you need my services.

Best regards,

name

Your name (optional):		

Did I meet your expectations?  (Please explain.)	

What parts of the work we did were you most satisfied with?	

Was there anything we did that you wish was done differently?	

Would you be willing to write a recommendation for me that I can use in my materials I share with others?  Please write one or two sentences:	

(Should I use your     Ο full name            or only your   Ο first name?)

Thank you.