HematoLogics Laboratory
Date of Event *
Enter the date the form is being filled out.
Customer Feedback Type *
Customer Name *
Please enter customer name and title, when applicable.
Customer Company/Organization *
Enter company or organization involved in the customer feedback. If the customer is a private entity, please enter "Private entity".
Customer State *
Customer Phone Number
Please enter the best phone number to contact the customer with follow up questions or updates.
Customer email
Please enter best email address to contact the customer with follow up questions or updates.
Date/Time of Customer's Lab Experience
When Did the Customer Contact the Lab?
Service(s) Involved *
Customer Feedback *