*PLEASE ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR EXPERIENCE IN OUR FACILITY BY FILLING IN THE BLANK OR CLICKING THE CIRCLE THAT BEST DESCRIBES YOUR ANSWER.

1. HOW LONG HAVE YOU REFERRED PATIENTS TO THIS FACILITY?
(PLEASE BASE YOUR ANSWERS ON YOUR CONTACT WITH THE FACILITY IN THE PAST 6 MONTHS.)

OR

2. HOW SATISFIED ARE YOU WITH HOW LONG IT GENERALLY TAKES:
(PLEASE RATE EACH ITEM BY CLICKING THE CIRCLE THAT BEST DESCRIBES YOUR OPINION.)

TO GET AN APPOINTMENT FOR A PATIENT AT THIS FACILITY?

TO OBTAIN WRITTEN REPORTS FROM THIS FACILITY ONCE YOUR PATIENT IS SEEN?

TO OBTAIN A VERBAL REPORT FROM THIS FACILITY WHEN IT IS REQUIRED BECAUSE OF AN URGENT OR EMERGENCY, ONCE YOUR PATIENT IS SEEN?

3. WHAT ARE THE REASONS YOU REFER PATIENTS TO THIS FACILITY?
(PLEASE RATE EACH ITEM BY CLICKING THE CIRCLE THAT BEST DESCRIBES YOUR OPINION.)

4. PLEASE RATE YOUR EXPERIENCE WITH OUR FACILITY BASED ON YOUR CONTACT WITH US IN THE LAST 6 MONTHS BY CLICKING THE CIRCLE THAT
BEST DESCRIBES THE FOLLOWING:

THE WAITING PERIOD FOR A TEST TO BE DONE IS LONG.

REQUESTS FOR CONSULTATION ARE HANDLED PROMPTLY.

THE FACILITY ACCOMMODATES PATIENTS WHEN THE TEST IS URGENTLY REQUIRED.

THE INTERPRETING PHYSICIAN IS AVAILABLE TO YOU FOR CONSULTATION.

THE FACILITY MEETS THE NEEDS OF MY PATIENTS WHOSE FIRST LANGUAGE IS OTHER THAN ENGLISH OR FRENCH.

THE RECOMMENDATIONS ARE CLEARLY STATED.

THE RECOMMENDATIONS RECEIVED ARE USEFUL IN PATIENT MANAGEMENT.

THE REPORTS ARE SENT OUT IN A TIMELY FASHION.

THE INTERPRETING PHYSICIAN’S FINDINGS ARE GENERALLY CONSISTENT WITH YOUR CLINICAL FINDINGS.

5. OVERALL, HOW SATISFIED ARE YOU WITH THE SERVICES PROVIDED WITH THIS FACILITY IN THE PAST SIX MONTHS?

6. IF THERE ARE ANY SUGGESTIONS ON HOW TO IMPROVE OUR SERVICES, PLEASE STATE BELOW:

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