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 best medical care to all our patients. We'd like to know how you feel about our services, our patient-handling systems, our providers and staff members. Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs. Thank you in advance for the time and thought you put into your response.
Untitled Title
Your Appointment:
Excellent
Very Good
Good
Fair
Poor
N/A
1. Your appointment was made in a reasonable amount of time
2. Waiting time in the reception area was reasonable...
3. Your check-in was handled courteously & efficiently...
4. Your check-out was handled courteously & efficiently...
Our Communication With You:
Excellent
Very Good
Good
Fair
Poor
N/A
5. Your phone call was handled in a prompt & courteous manner....
6. The receptionist was pleasant & professional...
7. The staff kept you informed if your appointment time was delayed....
8. Your phone call was returned in a timely manner...
Our Staff:
Excellent
Very Good
Good
Fair
Poor
N/A
9. The medical assistants were caring & courteous.....
10. Your billing & financial matters were handled properly..
Your Visit With Your Provider:
Excellent
Very Good
Good
Fair
Poor
N/A
11. Waiting time in the treatment room was reasonable..
12. The provider took the time to answer your questions..
13. Your provider spent adequate time with you...
14. The provider clearly explained your treatment options & follow-up care...
15. Your examination was thorough..
16. The provider made you feel comfortable during your treatment...
17. Medication instructions were clearly explained to you...
Our Facility:
Excellent
Very Good
Good
Fair
Poor
N/A
18. The hours of operation are convenient for you..
19. Signage & directions to our facility is easy to follow..
20. The parking facilities were adequate for your needs..
21. How would you rate the general appearance of our office?...
Your Overall Satisfaction:
Excellent
Very Good
Good
Fair
Poor
N/A
22. How would you rate the quality of your medical care?...
23. How likely are you to recommend a friend/family member to our practice?...
If there is any way we can improve our services to you, please tell us about:
Your answer
May we use your comments & only your first name on our web site?
Patient Name:
Your answer
Patient Phone:
Your answer
Date:
MM
/
DD
/
YYYY
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