Clinic Patient Satisfaction Survey

To be completed after Patient Visit

96 Harley Street, London W1G 7HY

Date:

Customer Satisfaction

Patient’s File No.:

Survey

DOB:

Very Satisfied

Satisfied

Dissatisfied

Very Dissatisfied

Availability Of Appointment

Ease Of Making an appointment

Ease Of Reaching the Helpdesk

Prompt Response By Receptionist

Waiting Time At The Clinic

The Look Of The Clinic

Cleanliness Of Clinic

Comfort Of Waiting Room

Satisfaction With The Examination

Understanding Of The Problem

Understanding Of The Treatment

Are You Happy With The Treatment

Please provide any additional comments and

overall impression that could help us to

improve our service should it be required.

Patients name:………………………………………………. Nationality………………………………………….Signature:…………………………..………

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Parent category: Life