Form

Thank you for taking the time to complete our survey. Your opinion is important to us and the information you provide will help us to improve our services. All information submitted will be confidential, but your opinions and responses will be used to help us maintain a high level of patient care and client satisfaction. Please share any comments you feel would help us improve our service to you and your pet and please note all fields are optional.

Clients who submit a survey and include their name will be entered in a monthly draw to win a $50.00 Gift Certificate

Remember to click on Submit Survey when you are done.

Your Name

First Name Last Name

Date of Last Visit

Month Day Year

Invoice Number (optional)

Name of most recent veterinarian

1. How did you choose our hospital?

Returning client I drove by and saw your hospital sign I saw the practice in the Yellow Pages Website Friend/Family Referral (if so who?)

2. Was our building easy to find?

Yes No

3. How would you rate the convenience of your appointment time?

Excellent Good Fair Poor

4. Did we accommodate your schedule when booking your appointment?

Yes No

5. How would you rate the friendliness of the front desk staff?

Excellent Good Fair Poor

6. How would you rate the cleanliness and appearance of the waiting area?

Excellent Good Fair Poor

7. Once you checked in, how long did you have to wait to be seen by a veterinarian?

I was seen before my scheduled time I was seen within 5 minutes of my scheduled time I waited for 5-15 minutes after my scheduled time I waiting for more than 15 minutes after my scheduled time

8. What time of day did you visit our clinic?

Weekday morning Weekday afternoon Weekday evening Weekend morning Weekend afternoon

9. How would you rate the veterinarian's friendliness and attitude?

Excellent Good Fair Poor

10. How well did the veterinarian listen to you during your exam?

Excellent Good Fair Poor

11. How would you rate the overall thoroughness of your pet's physical exam?

Excellent Good Fair Poor

12. How would you rate the speed of your check-out process?

Excellent Good Fair Poor

13. Overall, you would you rate the quality of your recent visit to Centennial Animal Hospital?

Excellent Good Fair Poor

....

14. How likely would you be to recommend Centennial Animal Hospital to a friend or family member?

Very Likely Somewhat Likely Somewhat Unlikely Very Unlikely

15. How likely would you be to return to Centennial Animal Hospital for your next veterinary visit?

Very Likely Somewhat Likely Somewhat Unlikely Very Unlikely

16. What did you like or appreciate the most about your recent visit to Centennial Animal Hospital?

17. What did you dislike about your recent visit to Centennial Animal Hospital?

If you would like the office manager to contact you regarding your experience, please fill in your contact information and the best time to contact you (phone number or email address):

Phone Number

- Area Code Phone Number

E-mail

Centennial Animal Hospital 2011 Survey