Wednesday, March 10, 2010
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American Animal Hospital Association

CLIENT SURVEY FORM
If you prefer to download our PDF form instead of using our online form, please click the link below and fax the completed form to 804-794-3015.
Client Survey Form
 
Since 1980, Midlothian Animal Clinic has been providing care to pets in Richmond and surrounding counties.  We are constantly evaluating our services as a part of our commitment to you and your pet.  We appreciate all feedback, and hope you will complete the survey below.  Please take a few minutes to help us determine how we can best serve you and meet your pet's needs.  Thank you very much for your participation.
Your Name:
Your E-Mail (optional):
Pet's Name:
Date/Approximate Date of Service:
Was this your first visit? Yes   No
How did you learn about our services?:
Doctor that examined your pet:

RATE US:

Please rate the following areas (choose appropriate answer):

Was your appointment at a time convenient to you and easy to schedule?
Yes Acceptable No
Professionalism on the phone
Exceptional Very Good Satisfactory O.K. but may be improved   Unacceptable
The ability of our employee(s) to handle all your questions while making the appointment?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable 
Were you able to find us easily?
Yes Acceptable No
Were you greeted immediately upon arrival at our office?
Yes Acceptable No
The manner in which you were greeted?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
Overall appearance of our hospital? (signage, landscaping building & parking lot)
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
Your impression of our hospital? (includes any odors, cleanliness, and overall appearance)
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The appearance of the exam room you were in? (odors, cleanliness, and overall appearance)
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The overall cleanliness of our hospital?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The courtesy and respect you received from the doctor(s) during your exam?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The courtesy and respect you received from our staff during your visit?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The knowledge and expertise of the Doctor(s)?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The knowledge, expertise and helpfulness of the staff?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
The Doctor's ability to communicate your pet's health status/prognosis?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
Value of care your pet received?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
Overall experience?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable
Overall ability to address your pet's health care needs?
Exceptional Very Good Satisfactory O.K. but may be improved Unacceptable

 
If your pet was hospitalized, were you provided with a written estimate? Yes   No
The reason for your pet's visit was:
How likely are to recommend this hospital to a friend or relative?
Was there a particular employee(s) that you would like to recognize for outstanding service during your visit?
As always, we welcome any additional comments you may have about your experience:
   
    
 

14411 Sommerville Court • Midlothian, VA 23113 • 804-794-2099 • Fax 804-794-3015 • info@macvetva.com