Satisfaction Survey
Your opinion counts! Thank you for your visit with us today. Please tell us your opinion about the service you received today. Your responses will be kept strictly confidential. Thank you for your help.
Sign in to Google to save your progress. Learn more
Are you a: *
Location: *
How did you learn about our services? *
Which service did you receive today? *
Did you have an appointment for today's visit? *
Your visit *
Excellent
Very Good
Good
Fair
Poor
Not Applicable
Ease of making an appointment
Ease of making a follow-up appointment
Appointment available within a reasonable amount of time
Ease of getting a referral when you needed one
Were you offered copies of the documents for your visit? *
Waiting time... *
0-15 minutes
16-30 minutes
31-45 minutes
46-60 minutes
60+ minutes
In the reception area after you checked in
In the exam room to see the Provider
Our staff *
Excellent
Very Good
Good
Fair
Poor
Not Applicable
The friendliness and courtesty of the FRONT office staff
The friendliness and courtesty of the BACK office staff
The professionalism of our staff
Your visit with the provider (Doctor, Physician Assistant, Nurse Practitioner, Registered Dental Hygienist) *
Excellent
Very Good
Good
Fair
Poor
Not Applicable
Willingness to listen carefully to you
Taking time to answer your questions
Amount of time spent with you
Explaining things in a way you could understand
Instructions regarding medication/follow-up care
The thoroughness of the examination
Advice given to you on ways to stay healthy
Our facility *
Excellent
Very Good
Good
Fair
Poor
Not Applicable
HOURS of operation conveinent for you
DAYS of operation convenient for you
Cleanliness of the WAITING ROOM
Cleanliness of the EXAM ROOM
Cleanliness of the BATHROOM
Your overall satisfaction with... *
Excellent
Very Good
Good
Fair
Poor
Not Applicable
The quality of our services
Your experience at this location
Would you return to this facility? *
Would you recommend us to your family and friends? *
Submit
Clear form
This form was created inside of Samuel Dixon Family Health Center, Inc.. Report Abuse
Google Forms