Patient Satisfaction Survey
Thank you for taking time out of your schedule to complete this satisfaction survey. This survey is completely voluntary and your responses will remain completely anonymous, unless otherwise noted. As always, our goal is to provide the best service we can to our patients.
Overall Rating
Poor
Excellent
Please rate the physician who provided care
Poor
Excellent
How were you treated by our front office?
Poor
Excellent
How were your treated by our nurses?
Poor
Excellent
If you were seen by the medical assistant, how were you treated?
Poor
Excellent
Were you seen at your schedule appointment time?
How well were your questions answered?
Poor
Excellent
How well were your treatment options explained?
Poor
Excellent
Was the front desk friendly and helpful?
Unfriendly/Not helpful
Very friendly/helpful
Please rate the appearance and cleanliness of the office
Poor appearance/unclean
Very clean/great appearance
Has all of the staff been courteous and helpful?
If no, please explain
Your answer
Are your phone calls to our nursing staff returned by the next business day?
Are your calls to our administrative staff returned by the next business day?
If not, who has not been returning your calls?
Your answer
Have any staff members been exceptionally courteous or helpful?
If yes, please give names
Your answer
Has any staff member not performed well in your opinion?
If yes, please explain who and why
Your answer
Would you recommend our services to a friend?
In one or two sentences, what would you tell a friend or colleague about your experience with FWF if they asked you for a recommendation?
Your answer
Any additional comments on what we could do differently or better?
Your answer
If you would like us to contact you to follow up on any of your comments, please provide us with your name and phone number where we may reach you and we will be sure to contact you as soon as possible.
Your answer
May we use your responses in our literature?
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