Patient Feedback

Patient Name

Type of Exam Done

Date of Visit

1. WAITING TIME: HOW LONG DID YOU HAVE TO WAIT TO GET AN APPOINTMENT AT THIS CLINIC?

2. WAITING TIME: HOW LONG DID YOU HAVE TO WAIT IN THE CLINIC WAITING ROOM FOR YOUR APPOINTMENT?

3. INSTRUCTIONS: HOW WELL DID THE CLINIC STAFF EXPLAIN THE A ON HOW TO PREPARE FOR THE TEST/S BEING DONE TODAY?

4. PROFESSIONAL APPEARANCE OF STAFF

5. PROFESSIONAL BEHAVIOUR OF STAFF

6. OVERALL RESPECT OF YOUR PERSONAL PRIVACY THROUGHOUT OUR VISIT

7. INSTRUCTIONS ON LEAVING: HOW CLEARLY AND COMPLETELY WERE YOU INFORMED ON WHAT TO DO OR WHAT AND WHEN TO EXPECT REPORTS WHEN YOU LEAVE THE CLINIC?

8. EASE OF LOCATING OUR DEPARTMENT

PLEASE RATE THAT BEST DESCRIBES YOUR OPINION:

WERE YOU TOLD TO LEAVE THE CLINIC BEFORE YOU FELT READY TO DO SO?

WERE YOU TOLD TO LEAVE THE CLINIC BEFORE YOU FELT READY TO DO SO?

WAS THIS FACILITY ABLE TO ACCOMMODATE ALL OF YOUR TEST/S ON THE SAME DAY?

WOULD YOU RECOMMEND THE CLINIC TO A FRIEND OR FAMILY MEMBER IF THEY NEEDED SERVICES THAT THIS FACILITY PROVIDES?

PLEASE RATE THAT BEST DESCRIBES YOUR OPINION:

OVERALL QUALITY OF CARE: HOW YOU EVALUATE THE SERVICES YOU RECEIVED AND THE WAY YOU WERE TREATED?

IF THERE WERE SOME THINGS YOU COULD CHANGE ABOUT THIS VISIT TO IMPROVE IT, WHAT WOULD THEY BE?