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Patient Satisfaction Survey
Dear Patient:

Would you take a few minutes of your time to help us? Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all our patients. We'd like to know how you feel about our medical services, our patient-handling systems, our physicians and staff members. Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs.

Thank you for your help.

How did you first hear about us?
HOW SATISFIED ARE YOU WITH:
YOUR APPOINTMENT: Very
Satisfied 		Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
Appointment available within a reasonable amount of time
Appointment scheduled at a convenient time of day
Waiting time in the reception area
Waiting time in the exam room
OUR STAFF: Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
The friendliness and courtesy of our receptionists
The caring concern of our nurses
The helpfulness of the people in our business office
The professionalism of our technical staff
OUR COMMUNICATION WITH YOU: Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
Your Emails & Phone Calls returned promptly
Availability of medical information/advice by telephone
Explanation of your test procedure (if applicable)
Your test results reported in a reasonable amount of time
Effectiveness of our health information materials
Your Healthcare Provider returning your emails in a timely manner
YOUR VISIT WITH THE HEALTHCARE PROVIDER: Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
The Healthcare Provider listening to you
The Healthcare Provider taking time to answer your questions
The Healthcare Provider adequately explaining treatment options
The thoroughness of the examination
Amount of time the Healthcare Provider spent with you
The outcome of treatment prescribed by your Healthcare Provider
Who is your Healthcare provider? (optional):
OUR FACILITY: Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
Hours of operation convenient for you
Overall comfort
Adequate parking
Signage and directions easy to follow
OVERALL RATING Excellent Good Fair Poor
Our Practice
The Quality Of Your Medical Care

Would You Recommend Our Pratice
to a Family Member or Friend?		YesNo

If there is any way we can improve our services to you, please tell us about it:



Your name/telephone number (optional):


Your email address (optional):


Which office did you visit (optional):




Thank you for your help!
 
 
 
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