Patient Survey

Date of Visit:

DD/MM/YYY

Examination Completed on this visit:

Name of Technologist

Was it easy to schedule an appointment?

technologist your and

Was administrative staff courteous and respectful?

Was your procedure started at your appointment time?

If not, how long did you wait?

Did the technologist explain the procedure and was communicative during the procedure?

Was the technologist(s) courteous and respectful?

Was the waiting room and atmosphere pleasant and accommodating to your needs?

Was the examination room clean and tidy?

Did you identify any barriers that limited your access to the service?

Please rate your overall experience at our clinic today?

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