C.L. Brumback Primary Care and Dental Clinic Patient Satisfaction Survey - Winter 2017
We want to be sure we are doing everything we can to serve you. Please take a minute to fill out this confidential survey. Just let us know what we are doing well and what we can do better! Thank you!
Date of your visit
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DD
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Your age:
Your answer
Please check one:
Clinic visited:
Name of provider (Dr./ARNP/RN/RDH) you have seen today:
Type of appointment (check one):
1. Please indicate your level of satisfaction with the following items related to your office appointment. Use a scale of 1 to 5, with 5 being Very Satisfied and 1 being Not at all Satisfied. If an item is not related to your care, choose N/A.
Not at all Satisfied (1)
Somewhat Not Satisfied (2)
Neutral (3)
Somewhat Satisfied (4)
Very Satisfied (5)
N/A
Getting through to the office by phone
The time between your call to schedule an appointment and your appointment date.
The manners of the person(s) who scheduled your appointment.
Clarity of directions to the office and the time of your appointment.
The professionalism and helpfulness of your reception.
Your wait time in the waiting room prior to seeing the provider.
Your wait time in the exam room prior to seeing the provider.
Your wait time after seeing the provider, but before you are able to leave the clinic.
The comfort, cleanliness and amenities of the reception area.
The extent to which staff respected your privacy.
2. Please rate the following items related to the delivery of your care. Use a scale of 1 to 5, with 5 being Excellent and 1 being Poor. If an item is not related to your care, choose N/A.
Poor (1)
Somewhat Poor (2)
Neutral (3)
Somewhat Satisfied (4)
Excellent (5)
N/A
Your physician/provider's listening skills.
His or her explanation of procedures, diagnoses or treatment regime.
His/her personal manner (courtesy, respect, sensitivity, friendliness).
Other staff's personal manner (courtesy, respect, sensitivity, friendliness.
Technical skills (thoroughness, carefulness, competence) of the physician/practitioner.
How prepared (records & educational materials readily available) the staff and physician/provider were for your visit.
3. Please indicate the extent to which you agree or disagree with each of the following statements. Use a scale of 1 to 5, with 5 being Strongly Agree and 1 being Strongly Disagree. If an item is not related to your care, choose N/A.
Strongly Disagree (1)
Somewhat Disagree (2)
Neutral (3)
Somewhat Agree (4)
Strongly Agree (5)
N/A
My physician/provider spent adequate time with me.
The service/care provided was valuable to improving my health.
The educational information I received was helpful.
I clearly understand the next steps in my plan of care.
4. If lab work was done, did you receive your lab results in a timely manner following your office visit?
5. Would you return to see this physician/practitioner for further care?
6. Do you have access to the Patient Portal?
7. Would you recommend this practice to family and friends?
8. How did you hear about us?
9. Did any specific staff member stand out?
If yes, who and why?
Your answer
10. Was there any aspect of your care that could be improved?
If yes, please explain?
Your answer
11. Please tell us what you liked best about the care you received.
Your answer
12. Please tell us what you liked least about the care you received.
Your answer
13. Other Comments
Your answer
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