You'll find a plain text file of this questionnaire here or a MS Word file here.
You should be able to right-click the link and choose "save target as" to copy these files to your own machine.

Please answer "yes" or "no" to the following:

Did we answer the phone promptly when you called for an appointment?
Was the telephone response friendly and courteous?
How promptly were you able to schedule a visit?
Were you able to find the clinic and to park conveniently?

From 1 (poor) to 10 (excellent) how would you rate the following:

How was the check-in proceedure and the staff member who checked you in?
How close to your scheduled appointment were we able to see you?
Was the technician who did the preliminary work friendly and competent?
How well did the doctor adequately explain the examination and diagnosis?
How well did the doctor adequately discuss your treatmant options?
How clear were your home-treatment and follow-up instructions
During check-out how well was your bill explained to you?
How did you feel about "value for money" for your visit?

Please tell us a little about the reasons for your visit, and if it was a non-routine visit please tell us how things worked out.
Please take a moment to tell us anything else about your visit you feel we should hear.
Please tell us if there are other services or products you'd like us to add.
May we follow up with a telephone call if there is anything in your responses we'd like to discuss with you?

Thank you for your time and for helping us improve!