LAKESHORE CANCER CENTER
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Patient Survey
Date of Service
MM
/
DD
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YYYY
Type of visit *
Which Department did you interact with on your visit?
Please indicate the level of satisfaction with the different elements of your clinic visit. If an element is not related to your visit, please tick N/A (Not Applicable) *
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
N/A
Ease of Contacting the clinic lines
Time Taken to schedule an appointment
Professionalism and Helpfulness of reception and administrative staff
Privacy was respected
The facility was clean and comfortable
Please indicate the level of satisfaction with the different elements of your clinic visit. If an element is not related to your visit, please tick N/A (Not Applicable) *
Not Satisfied
Somewhat Satisfied
Satisfied
Very Satisfied
N/A
The registration and check-in process were efficient and well-managed.
The Health Professional’s explanation of procedure, diagnosis and treatment regimen.
The Health Professional’s personal manner( courtesy, respect, sensitivity, friendliness).
I am satisfied with the care I received at Lakeshore Cancer Center
I clearly understand the next steps in my plan of care.
Did you book an appointment?
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Wait Time
Less than 30 minutes
30 minute to 1 hour
1 to 1.5 hours
1.5 to 2 hours
More than 2 hours
How long did you have to wait past your scheduled appointment or when you walked in? (Select One)
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How did we do?
Would recommend
Undecided
Would not recommend
I would recommend to a friend or relative
Clear selection
What is your overall impression of our practice?
What did you like best about our practice?
What can we do to improve?
Other comments, concerns?
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