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):