1.

Your name: *

 2.

Your Email: *

 3.

Date & Time of your visit:

Date:    Time: Midnight 12:30 AM 1:00 AM 1:30 AM 2:00 AM 2:30 AM 3:00 AM 3:30 AM 4:00 AM 4:30 AM Select Time 5:00 AM 5:30 AM 6:00 AM 6:30 AM 7:00 AM 7:30 AM 8:00 AM 8:30 AM 9:00 AM 9:30 AM 10:00 AM 10:30 AM 11:00 AM 11:30 AM Noon 12:30 PM 1:00 PM 1:30 PM 2:00 PM 2:30 PM 3:00 PM 3:30 PM 4:00 PM 4:30 PM 5:00 PM 5:30 PM 6:00 PM 6:30 PM 7:00 PM 7:30 PM 8:00 PM 8:30 PM 9:00 PM 9:30 PM 10:00 PM 10:30 PM 11:00 PM 11:30 PM *

 4.

Was the wait for your doctor too long?   Yes No

If so, by how long?

 5.

Was our Clinic:

Easy to find?   Yes No

Clean?   Yes No

Comfortable?   Yes No

Uncluttered?   Yes No

 6.

Did the support staff:

Greet you promptly?    Yes No

Greet you with a smile?   Yes No

 7.

Did the doctor:

Greet you with a smile?   Yes No

Acitively listen and respond to your concerns?   Yes No

Repeat your statements to check for clarity?   Yes No

Clearly explain your diagnosis?   Yes No

Clearly explain your treatment?   Yes No

Tell you what to do if treatment doesn't work?   Yes No

Show genuine concern?   Yes No

 8.

What could we do to improve our service?

 9.

Would you recommend us to friends or other family members?

   Yes No

10.

Would you like to receive emails from us for information about our new services?

   Yes No

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