Contact information:
First name:
Last name:
Phone Number: Email address:
Mailing address:
Request information on:
Best way to contact you: Email address Mailing address Phone N/A
General Patient Information:
In general, what is the quality of your pet's health? Outstanding Good Some Chronic Issues Poor N/A How often have you visited the Briargate Blvd. Animal Hospital within the past year? First Visit 2-5 visits More than 6 N/A
Scheduling Your Appointment:
Did you schedule an appointment by phone or did you drop in? Scheduled by phone Dropped in N/A If you scheduled an appointment, did you have to wait longer than expected to get scheduled? Yes No N/A How easy was it to make an appointment by telephone? Very easy Easy Moderately easy Difficult Very difficult N/A How long did you wait to speak to a scheduling staff member? 0 to 2 minutes 3 to 5 minutes 5 to 7 minutes Longer N/A Was the person who scheduled your appointment courteous and helpful? Very Courteous Friendly Rude N/A
Day of Your Appointment:
How would you rate the courtesy of the staff at the reception desk? Very Courteous Friendly Rude N/A How long did you wait in the reception area beyond your scheduled appointment time? 0 to 5 minutes 5 to 20 minutes 20 to 40 minutes Longer N/A How long did you wait in the exam room before the veterinarian appeared? 0 to 5 minutes 5 to 20 minutes 20 to 40 minutes Longer N/A How would you rate the competence of the technician who helped you? Outstanding Good Adequate Needs Improvement Poor N/A How would you characterize the concern that the technician showed for your problem? Outstanding Good Adequate Needs improvement Poor N/A Did the technician respond to your requests within a resonable period? Yes No N/A
The Doctor:
Which doctor did you visit with today? Dr. Brace Dr. Thompson Dr. Goble N/A Where you able to see the doctor of your choice? Yes No N/A Did you feel that your doctor spent an adequate amount of time with you? Yes No N/A Mark the box that characterizes the demeanor of your doctor: Attentive Concerned Friendly Distracted Rushed Inconsiderate N/A How would you rate the competence of your doctor? Outstanding Good Adequate Needs Improvement Poor N/A Did you feel that your doctor's examination was thorough? Yes No N/A Please rate the clarity of the doctor's explanation of your condition and treatment options. Outstanding Good Adequate Needs Improvement Poor N/A How well did your doctor include you in healthcare decisions? Outstanding Good Adequate Needs Improvement Poor N/A Were your questions answered to your satisfaction? Yes No N/A Would you recommend this facility and its staff to your family and friends? Yes No N/A
Additional Feedback:
Please list any area in which our service could be improved. Please share any additional comments. Would you like someone to contact you regarding your responses on this survey? Yes No N/A