Name* First Last Email* Phone*General Patient InformationHow would you rate our concern for you & your pet’s privacy? Outstanding Good Adequate Needs Improvement Poor N/A How often have you visited our practice within the past year? First Visit 2-5 Visits More than 6 Scheduling Your AppointmentDid you schedule an appointment by phone or did you drop in? Scheduled by Phone Scheduled Online Drop In If you scheduled an appointment, did you have to wait longer than expected? No Yes How easy was it to make an appointment by telephone? Very Easy Easy Difficult Very Difficult N/A How easy was it to make an appointment online? Very Easy Easy Difficult Very Difficult N/A Was the person who scheduled your appointment courteous and helpful? Very Courteous Courteous Indifferent Rude N/A Day of Your AppointmentHow would you rate the courtesy of the staff at the reception desk? Very Courteous Courteous Indifferent Rude N/A How long did you wait in the reception area beyond your scheduled appointment time? 0-5 Minutes 5-20 Minutes 20-40 Minutes More than 40 Minutes How long did you wait in the exam room before the veterinarian appeared? 0-5 Minutes 5-20 MInutes 20-40 Minutes More than 40 Minutes The Medical Support StaffDid the support staff member clearly identify themselves & their qualifications? Yes No How would you rate the competence of the technician/assistant who helped you? Outstanding Good Adequate Needs Improvement N/A How would you characterize the concern that the technician/assistant showed? Outstanding Good Adequate Needs Improvement N/A Did the technician/assistant respond to your requests within a reasonable period? Yes No How would you rate the professionalism and competence of the technician/assistant? Outstanding Good Adequate Needs Improvement N/A The DoctorWere you able to see the veterinarian of your choice? Yes No Did you feel that your veterinarian spent an adequate amount of time with you? Yes No What would describe the demeanor of your veterinarian? Attentive/Concerned Distracted Rushed/Inconsiderate How would you rate the competence of your veterinarian? Outstanding Good Adequate Needs Improvement Poor N/A Did you feel that your veterinarian’s examination was thorough? Yes No How do you feel about the clarity of the veterinarian’s explanation of your pet’s condition & treatment options? Outstanding Good Adequate Needs Improvement Poor N/A How well did your veterinarian include you in healthcare decisions? Outstanding Good Adequate Needs Improvement Poor N/A Were your questions answered to your satisfaction? Yes No Would you recommend this facility and its staff to your family and friends? Yes No Additional FeedbackPlease list any areas in which our service could be improved…Please share any additional comments…SignatureUntitled
