Client Center - Patient Survey Form

Patient Survey Form

Your responses to the questions on this survey will help us improve the care we provide. Participation in the survey is completely voluntary and all your responses to the survey will be kept confidential.

1. The last time you were sick or were concerned you had a health problem, how many days did it take from when you first tried to see your Nurse Practitioner to when you actually saw them or someone else at our clinic?


2. Did you get an appointment on the day you wanted or within an acceptable timeframe?

3. a) How many times in the past 12 months have you received care at a walk-in clinic or Emergency Department?

b) If you have received care at a walk-in clinic or Emergency Department, what was the reason for the visit?

4. a) Have you been admitted to the hospital in the past 12 months?

b) If yes, did you book or did someone call you from our clinic to book a follow-up appointment?
Note: We strongly recommend booking a post-hospital discharge follow-up within 7 days

5. a) Do you take prescription medication(s) on an ongoing basis?

b) If yes, in the past 12 months, did you review your medications with your Nurse Practitioner and/or Pharmacist?

6. When you see your health care provider(s), how often do they or someone else in our clinic...?

a) Give you an opportunity to ask questions about recommended treatment

b) Involve you as much as you want to be in decisions about your care/treatment

c) Spend enough time with you

7. We are a Team-Based health care model. Please let us know whom you saw in the past 12 months at our clinic location(s)?
Please check ALL that apply.

8. Did staff make you feel welcome at our clinic?

9. How would you rate your overall experience with our clinic?

10. Would you recommend our services to friends or your family?

11. Please list any areas in which our service could be improved or any other comments/suggestions about our clinic.

May we add your comments to our website?
Your responses will remain anonymous.