Patient Feedback Form

1. Which procedure did you have?

2. Please indicate your level of satisfaction

  Very Dissatisfied Dissatisfied Satisfied Very Satisfied
Appointment Booking  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied
Reception Staff  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied
Technologist  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied

3. Satisfaction of facility

  Very Dissatisfied Dissatisfied Satisfied Very Satisfied
Cleanliness of waiting room  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied
Cleanliness of exam room  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied
Convenience of hours  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied
Time spent in waiting room  Very Dissatisfied  Dissatisfied  Satisfied  Very Satisfied

4. How likely would you recommend ADI?

Not at all Neutral Extremely likely
 Not at all  Neutral  Extremely likely

5. We appreciate all of our patients experiences. Please let us know how we did, and what we could have done to make the experience better:

6. If you would like us to contact you in regards to your experience, please leave your contact information below:

Name* (required):

Email* (required):

Daytime Phone* (required):

Evening Phone* (required):