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):