Citywide Animal Clinic

Was this your first time visiting our hospital?

Yes

How did you first come to using Citywide Animal Clinic?
A friend referred me	A relative referred me	Telephone Book	Other
If you selected "Other", please enter how you found us here:

Date of Your Most Recent Visit(mm/dd/yyyy):

What time of the day was your appointment?
8am to 11am	11am to 2pm	2pm to 4pm	4pm to 7pm	7pm to 10pm

How many minutes did you wait after your scheduled apointment time before you were called to your pet's examination?:

The reason for this most recent visit:
Routine Physical Exam	Emergency Visit	Follow-Up/Recheck	Other
If you selected "Other", please enter the reason here:

My Pet's Doctor was:

If you were here for an appointment before, did you request the same doctor from this earlier visit?
Yes	No

If NO, Please choose from the following:
I believe that any of the doctors on staff are qualified to examine my pet.
I wasn't aware that you could request an appointment with a specific doctor.
My pet was sick, so I had to take an appointment with the next available doctor.
Other
If you selected "Other", please enter the reason here:

If YES, Please choose from the following:
The doctor was thorough/concerned at my earlier visit, and I wished to see him/her again.
I like the one-on-one communication I have with this particular doctor in his/her explanations of my pet's health and / or condition. All my questions were answered.
My pet really seemed to be relaxed with this doctor.
I like seeing the same doctor for my own health care needs. I believe I can establish a better relationship if I stay with one doctor.
The Nurse in with this doctor makes my pet and myself at ease, answering all of our questions.
Other
If you selected "Other", please enter the reason here:

On a scale of 1(Unacceptable) to 5(Excellent) please rate the following items:
ITEM	1	2	3	4	5
Reception / Sign In
Helpfulness of the person at the registration desk:
Appropriateness / Comfort of the waiting area:
Waiting time at the registration desk:
Ease of registering and chekcing out:
Your Pet's Examination / Overall Visit
Confidence in the Doctor:
Friendliness/Concern of the Nurse:
Skill/Helpfulness of the Nurse:
Doctor's/Nurse's concern for your pet's comfort:
Concern for your pet's condition:
Value received for money:
Facility
Parking/Outside Lighting:
Cleanliness of the Facility:
Ease of Access, both inside and outside:
Overall Assessment
Overall rating of the care you received during your visit:
Overall knowledge and skill level of our staff:
Likelihood of your recommending our facility to others:

Please add any additional comments or suggetions below. Again, we value your comments. They are vital to providing the services you desire with the medical care your pet needs.

Other Services: Please check all that apply:

I was aware that I could receive my pet's annual reminders by eMail as well as by regular mail.

I was aware that Citywide Animal Clinic scheduled appointments until as late as 10:00 PM every weeknight.

I find the website helpful and informative.

I learned more about Citywide Animal Clinic's services when I was there during my last visit. If yes, pleae selct all that apply below.

I picked up a hospital brochure.

I read the doctor's "bios" posted in the hospital waiting area.

I asked questions of your receptionists.

I asked the doctor and the nurse during my appointment.

I find the website helpful and informative.

Other Comments? Questions? Observations? Feel free to enter them here:

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