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Client Satisfaction Survey

Please note the following information will be sent via E-mail which is NOT secure. Do NOT include any credit card numbers or other sensitive information. NOTE: There is space provided below for any comments/suggestions or specifics. Please feel free to answer any or all of this form. All comments/suggestions are welcome!
What was/were your main reason(s) for selecting our hospital?	Friend / relative recommendation Heard the hospital was good We had an available opening when you called. Do not know / remember. Other:
When You Have CALLED Our Office, how has Our Reception Staff treated you:
Attitude?	Very friendly Friendly Just Tolerant Rude
Courtesy?	Very Courteous Courteous enough Discourteous
When You Have VISITED Our Office, how has Our Reception Staff treated you?
Were you greeted promptly?	Yes No
Attitude?	Very friendly Friendly Just Tolerant Rude
Courtesy?	Very Courteous Courteous enough Discourteous
Roughly, the time of your visit:	Before 5pm After 5pm
Were you seen by a doctor in a reasonable amount of time?	Yes No
Was the doctor's attitude good, and professional?	Excellent Good Fair Poor
Did the doctor take time to fully explain your pet's condition?	Yes Only Fair No
Was your checkout efficient and pleasant?	Excellent Good Passable Poor
Overall, how would you describe your experience at our Hospital?	Excellent Good Passable Poor
Please feel free to give us any comments or suggestions to help us reinforce or change our practice:
Optional Name:
Pet(s) Name(s):
Would you LIKE us to CALL you to follow up on this?	Yes -- be sure to leave a phone number below!! No
Would you MIND if we did CALL you to follow up on this?	It is all right if you do call -- be sure to leave a phone number below!! Please don't call on this!
Phone Number to CALL:

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