Patient Consultation Survey

Name *

Consultation Date

Was your call to our facility answered promptly and efficiently?

During your first contact with WLEI was the staff friendly and informative?

On consultation day what was your impression of the facility and our staff?

Did your consultation commence at the appointed time? If not, how long did you wait?

How complete did you find the consultation process in terms of patient education?

How could we have made the visit more beneficial to your particular needs?

On a scale of 1-10 (10 being the highest) please rate our reception staff on your day of consultation.

On a scale of 1-10 (10 being the highest) please rate our clinical staff on your day of consultation.

On a scale of 1-10 (10 being the highest) please rate our doctors on your day of consultation.

On a scale of 1-10 (10 being the highest) please rate your overall experience on your day of consultation.

Please feel free to comment further.

At any time, were our educational materials provided to you?

Are there any suggestions for additions or improvements of this material (brochure and DVD)?

How did you hear about us? Please specify media: i.e., television, radio, print, billboard or other?

Have you or do you intend to schedule surgery?

If no, why?

Any additional comments to better serve our patients are welcomed.