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Client Satisfaction Survey Form (#3)
Patient Survey
This survey is to enable us to gain valuable insights about our patients. It should only take 5 minutes to complete.
All responses are confidential and anonymous, unless you provide your name to provide additional feedback.
Thank you.
Overall Experience
How satisfied are you with your recent visit to our medical centre?
Very satisfied
Satisfied
Neutral
Dissatisfied
Very dissatisfied
Would you like to make any further comments?
Appointment Process
How easy was it to schedule an appointment that met your needs?
Very easy
Easy
Neutral
Difficult
Very difficult
Would you like to make any further comments?
Wait Time
How long did you wait before being seen by a healthcare provider?
Less than 15 minutes
15 – 30 minutes
30 – 45 minutes
More than 45 minutes
Would you like to make any further comments?
Staff Interaction
How would you rate the friendliness and professionalism of our staff?
Excellent
Good
Average
Below average
Poor
Would you like to make any further comments?
Quality of Care
Did you feel that your healthcare provider listened to your concerns and answered your questions?
Yes, completely
Yes, somewhat
No
Would you like to make any further comments?
Cleanliness & Comfort
How would you rate the cleanliness and comfort of our facilities?
Excellent
Good
Average
Below Average
Poor
Would you like to make any further comments?
Likelihood to Recommend
How likely are you to recommend our medical centre to friends or family?
Very likely
Likely
Neutral
Unlikely
Very Unlikely
Would you like to make any further comments?
Additional Feedback
Is there anything else you would like to share about your experience or any suggestions for improvement?
If you would like to be contacted by our Business Manager to discuss further, please indicate below.
Yes
No
First Name
Last Name
Phone/Mobile
Email if preferred
Submit
