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* 1. Which clinic did you visit/attend?

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* 2. The ease of physical access into the clinic was…

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* 3. Car parking availability was ....

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* 4. How clear and adequate are the external signage directing you to the clinic?

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* 5. Informative internal signage showing fees, services & open hours is...

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* 6. How satisfactory are our opening hours in relation to your needs?

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* 7. How safe and secure do you feel in or around Shorecare?

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* 8. The general cleanliness of the clinic is .....

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* 9. Encouragement to bring family/whanua into the consultation was ....

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* 10. The respect shown for my privacy was....

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* 11. The respect shown for my dignity was ....

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* 12. The staff's concern for me as an individual was ...

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* 13. How well did the staff listen to your concerns and fears

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* 14. The chance for me to ask questions was ....

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* 15. The level of care and skill provided was ...

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* 16. How good was the explanation of treatment options?

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* 17. Communication regarding follow-up plans and access follow up care was ....

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* 18. Information regarding accessing and/or receiving test results was ....

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* 19. Consideration of my culture when choosing treatment or advising me was ...

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* 20. How well were your wishes considered and those of your family/whanau when deciding treatment?

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* 21. The time to be seen by a Doctor was ...

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* 22. The amount of time given to me for this visit was ...

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* 23. Information on how to access primary care services (e.g. a GP) was ...

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* 24. Awareness, signage and availability of information regarding the complaint process is..

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* 25. My overall satisfaction with this visit to the clinic is ...

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* 26. The chance of my returning to use this clinic is ....

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* 27. Is there anything we could have done to improve our service ?

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* 28. Where did you hear from us?

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* 29. How old are you?

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* 30. Day of visit:

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* 31. Time of visit:

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* 32. Are you:

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* 33. Are you:

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