Patient Satisfaction Survey

Etobicoke Brampton Sleep Clinic

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Patient Information

Last Name *

First Name *

Date of Birth *

Patient Satisfaction Survey

Question Narrative	Response Options
1. Did you have any difficulty with our location or parking?	Yes No
2. When you had your consultation with the physician, did they adequately address your concerns?	Yes No
3. Were you given enough information to prepare for the sleep test?	Yes No
4. Were all your questions answered by the technologist?	Yes No
5. Was your waiting time for the appointment reasonable?	Yes No

6. Rate us on a scale of 1 (POOR) to 5 (EXCELLENT):

Cleanliness of the clinic

1 2 3 4 5

Noise level in the bedroom

1 2 3 4 5

Room temperature

1 2 3 4 5

Professionalism of our staff

1 2 3 4 5

Staff's willingness and Promptness to assist you

1 2 3 4 5

Overall, how satisfied you are with the care at our facility

1 2 3 4 5

Any additional comments:

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Our physicians are highly skilled and widely experienced in the field of sleep medicine. We are committed to providing clinical, educational and technical excellence, respect, integrity and compassion to those persons who entrust us with their sleep health. Accredited ICHSC Integrated Community Health Services Centres Quality Assurance Program

106 Humber College Blvd. Suite 202 Etobicoke, ON M9V 4E4

Patient Satisfaction Survey

6. Rate us on a scale of 1 (POOR) to 5 (EXCELLENT):

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