Name *

First

Last

Email *

General Patient Information

How would you rate our concern for you & your pet’s privacy? *

How often have you visited our practice within the past year? *

First Visit
2-5 Visits
More than 6

Scheduling Your Appointment

How did you schedule the appointment? *

Phone Call
Online
Drop In

If you scheduled an appointment, did you have to wait longer than expected?

No
Yes

How easy was it to make an appointment by telephone?

How easy was it to make an appointment online?

Was the person who scheduled your appointment courteous and helpful?

Day of Your Appointment

How would you rate the courtesy of the staff at the reception desk? *

How long did you wait in the reception area beyond your scheduled appointment time? *

0-5 Minutes
5-20 Minutes
20-40 Minutes
More than 40 Minutes

How long did you wait in the exam room before the veterinarian appeared? *

0-5 Minutes
5-20 Minutes
20-40 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? *

How would you characterize the concern that the technician/assistant showed? *

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?

The Doctor

Were you able to see the veterinarian of your choice? *

Yes
No

Did you feel that your veterinarian spent an adequate amount of time with you? *

Yes
No

How would describe the demeanor of your veterinarian? *

Attentive/Concerned
Distracted
Rushed/Inconsiderate

How would you rate the competence of your veterinarian? *

Did you feel that your veterinarian’s examination was thorough? *

Yes
No

How do you feel about the clarity of the veterinarian’s explanation of your pet’s condition & treatment options? *

How well did your veterinarian include you in healthcare decisions? *

Were your questions answered to your satisfaction? *

Yes
No

Additional Feedback

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

Please share any additional comments…

Client Feedback Form

We’d love to hear your feedback!

Full-service veterinary care in Adel, IA.

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