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Form - Client Questionairre Form

How did you choose our office? :
Parking Lot/Grounds:
Clean
yes
no
Large Enough
yes
no
The reception area:
Comfortable
yes
no
Neat and Clean
yes
no
Odor Free
yes
no
Child Friendly
yes
no
The receptionist(s):
Stood and greeted me
yes
no
Seemed warm and cheerful
yes
no
Gave me undivided attention
yes
no
Seemed hospitable
yes
no
Answered all my questions
yes
no
When I telephoned:
I did not phone
My call was answered promptly
yes
no
unsure
My appointment was easy to make
yes
no
I was placed on hold too long
yes
no
unsure
The staff member I spoke to on the phone was:
I did not phone
Friendly and attentive
yes
no
Courteous
yes
no
Informative & Knowledgeable
yes
no
The technician:
Greeted me with warmth and by name
yes
no
Was gentle with my pet
yes
no
Was proficient and knowledgeable
yes
no
Gave me the information I needed
yes
no
The veterinarian:
Introduced himself/herself
yes
no
Listened to what I said
yes
no
Described, Diagnosed, and treated my pet well
yes
no
Answered all of my questions
yes
no
Was interested in what I had to say
yes
no
Was clear on my pet's treatment plan
yes
no
The veterinarian was:
Professional in manner and appearance
yes
no
Good at comforting me and my pet
yes
no
Able to make me feel like a friend
yes
no
Miscellaneous
Was your waiting time reasonable
yes
no
Are the office hours convenient
yes
no
If you marked "No", please specify times that would be more convenient for you to visit

Did you understand our fees
yes
no
If you marked "No," please explain:

Do you feel the fees are reasonable
yes
no
If you marked "No," please explain

Have you recommended us to others
yes
no
Why or why not

What suggestions do you have for improving the office, staff, or procedures

Name (Optional)


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