Clinic Mystery Shopper Survey Form
Please complete this survey to share your experience evaluating the clinic visit. Your feedback helps us improve our service quality.
Date of Visit
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Overall Satisfaction
*
1
2
3
4
5
Front-Desk Check-In Experience
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Staff Courtesy
*
Not Courteous
1
2
3
4
Very Courteous
5
1 is Not Courteous, 5 is Very Courteous
Wait Time Before Being Seen
*
Less than 5 minutes
5-15 minutes
16-30 minutes
More than 30 minutes
Cleanliness of the Clinic
*
Very Poor
1
2
3
4
Very Clean
5
1 is Very Poor, 5 is Very Clean
Clinic Ambiance
*
Unpleasant
1
2
3
4
Excellent
5
1 is Unpleasant, 5 is Excellent
Did the staff clearly explain the next steps?
*
Yes
No
Partially
Additional Comments or Suggestions
Submit Survey
Should be Empty: