Doctor Visit Survey

Name (Optional)

Date of visit:

Approximate time:

How did you hear about us?

If other, please explain:

When you entered the clinic were you greeted with a smile by a receptionist?

Were staff members wearing uniforms/name tag?

Did employee appearances seem professional?

Was the reception area clean and orderly?

The receptionist attitude was:

Were you informed at check in about the wait time?

Did receptionist ask you to verify your current address and phone number?

The vet assistant/technician attitude was:

Did the technician/vet assistant tell you what was happening throughout the visit?

Did technician/vet assistant go over the estimate/treatment plan with you?

The veterinarian was:

Did the technician/vet assistant perform a physical exam on your pet?

Did the technician/vet assistant ask you if you had any questions or concerns before concluding the visit?

Did technician/vet assistant review medications and treatments prior to discharge?

Were you told when to return for recheck or follow up care (vaccine boosters, suture removal etc)?

At check out, did receptionist review charges with you?

On a scale of one to ten, with ten being the best, how did the clinic rate?

What were the best aspects of your visit?

What were the weakest aspects of your visit?

If you would like a manager to contact you regarding this survey, please provide your name and phone number or email address.

Your Name:

Your Phone:

Your Email: