Client Survey

Form - Client Satisfaction Survey

Name
First Name	Last Name

How long have you been with our clinic? (required)
Less than 1 year
Less than 5 years
More than 5 years

The Clinic:

General Appearance (required)
Poor
Acceptable
Great

Comfort Level While in the Clinic (required)
poor
Acceptable
Great

Smell of the Clinic (required)
poor
Acceptable
Great

Accessibility to Merchandise (required)
Poor
Acceptable
Great

Please comment on areas you feel we need to improve on:

Staff:

Welcome & Reception (required)
Poor
Okay
Great

Medical Care Coordinator
Poor
Okay
Great

Dr. Bell or other attending Vetrinarian (required)
Poor
Okay
Great

Veterinary Technician
Poor
Okay
Great

Please comment on ways our staff can improve:

Communication:

What do you prefer?
Please rank the following forms of communication (1=best, 4=worst) with regards to how you would like to be contacted for clinic information or appointment reminders.

Email (required)
1
2
3
4

Telephone (required)
1
2
3
4

Text Message on your cell (required)
1
2
3
4

Mail (required)
1
2
3
4

Please provide us with your top 2 contacts so we can keep your information up-to-date:

1) :

- (required)

2) :

- (required)

Would you be interested in receiving a monthly newsletter?

Please comment on anything else you would like us to know about:

Note:
**Please make sure you have included your name if you wish to be contacted for reminders or want to receive a newsletter. Thank you!

The verification code below ensures the form is not submitted by a computer

Verification Code :

Enter the code you see in the graphic below in this box.
Your post will not be allowed if you do not type this in correctly.

3555 Ravine Way, Victoria, BC V8X 4Z1
(250) 475-2287
paccat@shaw.ca