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Appointment
Request
Did the
Employee give you their name?
Yes
No
Additional
Comments:
Were they
informative/accommodating?
Yes
No
Additional
Comments:
Were you told of on-line services?
New Client Form
Coupon
Other:
Other appointment related comments:
Appearances
What were your
impressions of the exterior of the practice,
including sign and parking lot?
Were you promptly greeted upon arrival?
Yes
No
Additional
Comments:
Were the staff members wearing name badges?
Yes
No
Additional
Comments:
Did the employee appearances seem professional?
Was the inside of the practice...
Clean and tidy
Untidy but
overall clean
Untidy and
smelly
Other appearance related comments:
Client Service
Staff members' attitudes were:
Friendly and helpful
Nice
enough, but distracted
Unfriendly and unhelpful
Comments (try to use staff names):
Did the team members talk to you about other services,
vaccinations,
or care your pet needed?
Yes
No
Additional
Comments:
The doctor's attitude was:
Friendly and helpful
Nice
enough, but distracted
Unfriendly and unhelpful
Unfriendly and unhelpful
Comments (try to use doctor names):
Did you have to wait to be seen?
Yes
No
How long?
Did the staff call you by name?
Yes
No
Did the staff use your pet's name?
Yes
No
Was a technician present in the exam room?
Yes
No
Additional Comments:
Were you given a magnet or other souvenir of your first visit to
MPAH?
Yes
No
Additional Comments:
Other client service comments:
Client Education
Did the doctor use a pamphlet or brochure to help explain
products or services?
Yes
No
Not
Applicable
Did you receive notes summarizing your visit and any
recommendations made by the doctor?
Yes
No
Additional Comments:
Did the doctor ask you if you had other questions or concerns
before exiting the room?
Yes
No
Additional Comments:
Please describe your overall experience: (required)
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