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Date of (last) visit *	(dd-mm-yyyy)
Please identify which department you visited *	Other, namely:
Name of Therapist
Length of time to get an appointment:	excellent very good good fair poor
Convenience of Clinic Hours	excellent very good good fair poor
Friendliness and courtesy of the staff	excellent very good good fair poor
Satisfaction with facility and medical equipment used	excellent very good good fair poor
The visit overall	excellent very good good fair poor
Physician or Practitioner Satisfaction
Quality of care provided by the physician or practitioner:	excellent very good good good fair poor
Communication with physician or practitioner	excellent very good good fair poor
Information from tests relayed in a timely manner:	excellent very good good fair poor
Would you recommend this physician or practitioner?	Definitely yes Probably yes Probably not Definitely not
Would you recommend the IHCH to others?	Definitely yes Probably yes Probably not Definitely not
We welcome your input. Please leave your additional comment.
Additional comments:
If you would like someone to contact you please leave your name and email-address
e-mail
Mr	Mr
Mrs	Mrs
Last name
* compulsory question

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