General Patient Information

How 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 then 6

Scheduling Your Appointment

Did 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 Appointment

How 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 then 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 then 40 Minutes

The Medical Support Staff

Did 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 Poor N/A

How would you characterize the concern that the technician/assistant showed?

 Outstanding Good Adequate Needs improvement Poor 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 Poor N/A

The Doctor

Were 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 Feedback

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Other Medications:

Which is greater, 9 or 3? 

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