PATIENT SATISFACTION SURVEY
Your satisfaction with our services is very important to us.
To assist us in monitoring the quality of our services,please take a few minutes to complete this questionnaire.
Date of visit:
Gender: Male Female Transgender
Age: Less than 18 19-45 46-65 66-75 76 and over
This questionnaire is being completed by : Self Caregiver / Parent
Instructions – Please indicate how much you agree with the statements on the left side of the page using the following scale:
1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree
My appointment time was convenient for my lifestyle. 1 2 3 4 5 Na
The clinic was easy to find.
The clinic was clean and comfortable.
I was taken care of in a timely fashion upon my arrival.
Explanations and instructions were given clearly upon appointment booking.
The clinic staff were helpful, pleasant and knowledgeable.
General Comments/Suggestions for improvement: