Forms

How Are We Doing?

Please take a few minutes to fill out this survey on the timeliness and quality of the service you received today. We welcome your feedback and your answers will be kept confidential. Please fill in the corresponding circle that best fits your answer.

Thank you for your participation.

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 Victoria Veterinary Clinic within the past year?	First Visit 2-5 Visits More than 6

Scheduling Your Appointment

Did you schedule an appointment by phone or did you drop in?	Scheduled by phone Dropped in
If you scheduled an appointment, did you have to wait longer than expected?	Yes No
How easy was it to make an appointment by telephone?	Very easy Easy Normal Difficult Very difficult
Was the person who scheduled your appointment courteous and helpful?	Very courteous Courteous Normal Rude Very rude

Day of Your Appointment

How would you rate the courtesy of the staff at the reception desk?	Very courteous Courteous Normal Rude Very rude
How long did you wait in the reception area beyond your scheduled appointment time?	0 to 5 minutes 5 to 20 minutes 20 to 40 minutes More than 40 minutes
How long did you wait in the exam room before the veterinarian appeared?	0 to 5 minutes 5 to 20 minutes 20 to 40 minutes More than 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 N/A
Did you feel that your veterinarian spent an adequate amount of time with you?	Yes No N/A
Mark the boxes that characterize the demeanor of your veterinarian:	Attentive Concerned Friendly 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 N/A
Please rate 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 N/A
Would you recommend this facility and its staff to your family and friends?	Yes No N/A

Additional Feedback

Please list any areas in which our service could be improved.

Please share any additional comments.

Form Validation

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Thank you for taking the time to fill out our survey. We rely on your feedback to help us improve our services. Your input is greatly appreciated.