Your name:

Deceased:

Relationship to the Deceased:

Funeral Director:

1. Are there any unanswered questions regarding the service? Yes No

If so, please allow us the opportunity to answer your questions:

2. Did we explain the different funeral goods and services to your satisfaction? Yes No

3. Do you need any of the following?

Additional Acknowledgment Cards: Yes No

Additional Certificates of Death: Yes No

Help in Obtaining Change of Beneficiary Forms: Yes No

4. Prior to the arrangement conference, did you know we have information available on the following?

Additional Cemetery Spaces: Knew Did Not Know Need More Info

Advance Funeral Planning: Knew Did Not Know Need More Info

Community Support Groups: Knew Did Not Know Need More Info

Durable Power of Attorney for Your Health Care: Knew Did Not Know Need More Info

Emergency Information Card: Knew Did Not Know Need More Info

Forms for Applying for Lost Insurance Policies: Knew Did Not Know Need More Info

Financial and Credit Obligations: Knew Did Not Know Need More Info

Living Wills: Knew Did Not Know Need More Info

Obtain Historical Records: Knew Did Not Know Need More Info

Organ Donation: Knew Did Not Know Need More Info

Purchasing a Monument, Marker or Mausoleum: Knew Did Not Know Need More Info

Social Security Benefits: Knew Did Not Know Need More Info

Transition Counselors: Knew Did Not Know Need More Info

Veteran's Benefits: Knew Did Not Know Need More Info

Weekly Luncheon Program: Knew Did Not Know Need More Info

Wills: Knew Did Not Know Need More Info

5. Making funeral arrangements at the time of death is a difficult and emotional experience. In which of the following areas if any were your main concerns?

Not knowing what to expect

Choosing the appropriate service, casket and vault

Anticipated expense

Making major decisions at this time

Other

6. Would selections have been easier if information on funeral options and costs had been available to you previously? Yes No

7. Have you used our funeral home previously? Yes No

8. How would you rate the following characteristics of our funeral home:

Convenience of Location: Above Average Average Below Average

Facilities of our Firm: Above Average Average Below Average

Reputation of our Firm: Above Average Average Below Average

9. If a friend asked about our services, what would you tell them about our firm?

10. Was there anything more the funeral director in charge or the staff could have done?

11. The extended services we offer are for all members of the family. Please list the names, addresses and telephone numbers of all family members who may have a need of these services:

12. Thank you again for sharing your comments. Our goal is to fulfill the needs and exceed the expectations of the families we serve.

Today's Date:

Your Electronic Signature: