Clinic Quality Assessment Form
Please complete this Clinic Quality Assessment Form to help us evaluate the overall quality of the clinic. Your feedback is important for continuous improvement.
How would you rate the overall cleanliness of the clinic?
*
1
2
3
4
5
How would you rate the professionalism of the clinic staff?
*
1
2
3
4
5
How satisfied are you with the waiting time before being attended to?
*
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
How comfortable and welcoming is the clinic’s environment?
*
Not Comfortable
1
2
3
4
Very Comfortable
5
1 is Not Comfortable, 5 is Very Comfortable
How would you rate the availability and condition of clinic equipment?
*
1
2
3
4
5
Please indicate whether the following aspects were satisfactory.
*
Rows
Yes
No
Reception experience
1
2
Restroom cleanliness
3
4
Signage and directions
5
6
Accessibility for all patients
7
8
How clear and helpful was the communication from staff?
*
Unclear
1
2
3
4
Very Clear
5
1 is Unclear, 5 is Very Clear
Did you observe the clinic following safety and hygiene protocols?
*
Yes
No
Not Sure
Which of the following areas do you feel need improvement? (Select all that apply)
Cleanliness
Staff professionalism
Waiting time
Facility comfort
Equipment
Communication
Safety protocols
Other
Please share any additional comments or suggestions about the clinic’s quality.
Submit Assessment
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