Client Feedback Form

This form will help us to know your thoughts on how we can improve your experience at Bottleneck Medical Virtual Services. It can also serve as an evaluation tool prior to a pay raise or to discipline a virtual assistant (VA) for lack of action or follow through. 

Note: Fields marked with an asterisk (*) are required.


  • (Enter the email address where you would like your completed form to be sent.)
  • (Please submit separate forms if you have multiple virtual assistants.)
  • MM slash DD slash YYYY
  • How accurate and complete is the VA's work? Consider the degree to which the work meets acceptable standards.
  • Does the VA produce an acceptable amount of work? Consider how effective the VA uses available working time, plans and prioritizes work, sets and accomplishes goals and completes assignments on schedule.
  • Is the VA familiar with the responsibilities and requirements as well as the methods, practices and tools to do the job? Consider knowledge gained through experience, education and specialized training to stay updated in the field.
  • How well does the VA see things to be done, adapt to changes and take action? Consider ability to contribute, develop and/or carry out new ideas or methods.
  • How reliable is the VA in performing assignments? Consider degree of supervision required, ability to take on responsibilities and willingness to be accountable for them.
  • Does the VA exercise the ability to decide, correct or choose the best course of action when some decision must be made? Consider ability to evaluate facts, make timely decisions and use logic to identify, solve and prevent problems.
  • Does the VA work effectively with others (customers, supervisors, peers, subordinates)? Consider respect and courtesy shown to others, willingness to accept supervision, and overall attitude exhibited. Are manners and sociability appropriate to the job responsibilities?
  • How reliable is the VA in reporting to work and completing their scheduled shift? Consider arrival times, observance of time limits for breaks and lunches. Consider patterns of sick leave, prior approval for vacation and prompt notice of absence due to illness.
  • How prepared is the VA to perform the job requirements? Consider frequency of Internet connectivity and power outage problems, availability of backup WIFI or alternate work location, quality of equipment and equipment upkeep (headset, monitor, computer).
  • How well does the VA communicate? Consider effectiveness in listening to others, expressing ideas (both orally and in writing), and providing relevant and timely information to manager, peers, subordinates, customers and clients.
  • What can you say about your VA's overall performance for this review period?
  • What is the action that you would like to take based on your experience with your VA? (i.e., We want to give our VA a raise or we are happy with our virtual assistant and would like to continue our existing relationship, etc.)
  • Would you like to give Bottleneck Medical Virtual Services a testimonial? Use the space below to share your story with others on our website or social media.
  • We would love to include your headshot in your testimonial.
    Max. file size: 16 MB.
  • Name/Contact Info
  • Thank you for taking the time to send us your feedback. For inquiries, feel free to contact