TELEPHONE INQUIRY

Was the phone answered in 3 rings or less? Y / N

Was the name of the practice used? Y/N

Were you put on hold? Y / N

If yes, for how long? ____________

Was the greeting polite and professional? Y / N

CHECK IN / RECEPTION / COMMON AREAS

Were you acknowledged upon approaching the reception desk? Y / N

Was the receptionist well groomed and professional in appearance? Y / N

Was your privacy, and that of other patients, protected? Y / N

Was the check in paperwork clear and relevant? Y / N

Was the waiting area clean and comfortable? Y / N

PRESCREEN / INITIAL SERVICES DENTAL

Was the hygienist/assistant polite and professional in demeanor? Y / N

Did the hygienist/assistant demonstrate knowledge and proficiency? Y / N

Did the hygienist/assistant tell you how long you would wait for the Dentist? Y / N

EXAM ROOM DENTAL

Did the Dentist introduce him/herself? Y / N

Did the Dentist explain procedures and ensure your comfort? Y / N

Did the Dentist have a gentle touch? Y / N

EXAM ROOM PLASTIC SURGEON

Was the surgical procedure you were inquiring about explained fully? Y / N / NA

Did the Plastic Surgeon discuss his/her experience with this procedure? Y / N / NA

Did the Doctor listen to you and was he/she receptive? Y / N

EXAM ROOM OPTOMETRIST

Were your questions answered to your satisfaction? Y / N

If a prescription was given, was it explained? Y / N / NA

Do you feel the Optometrist spent enough time with you? Y / N

EXAM ROOM VETERINARIAN

Did the Doctor introduce him/herself? Y / N

Did the Doctor relate well to your pet, try to put the pet at ease? Y / N

Did the Doctor explain procedures and ensure your pet’s comfort? Y / N

CHECK OUT / BILLING

Name, or accurate description, of check out person ______________

Were you acknowledged upon approach to the check out counter? Y / N

Were you given all appropriate receipts? Y / N