Your opinion matters to us.
Please take a moment to complete the form below.
Patient Satisfaction Survey
Your thoughts and comments give us the tools to learn. If we are measuring up to your expectations, we want to know. But we also need to know if we are falling short of those expectations. This feedback section is very helpful to us. In your comments, try to think of what type of information you would look for if you were reading reviews from other people like yourself.
Please chose your physician below. *
Who referred you to our survey?
Please provide 3-4 sentences about your experience and/or procedure (if applicable):
Your answer
How would you rate the doctor / clinical staff overall? *
1 = Poor, 10 = Excellent
Would you recommend the doctor to family / friends? *
1 = Poor, 10 = Excellent
Ease of getting timely appointment after requesting one? *
1 = Poor, 10 = Excellent
Time you waiting in the waiting room? *
1 = Logest, 10 = Shortest
Waiting time once in a room? *
1 = Logest, 10 = Shortest
Did the doctor (or clinical staff) spend enough time with you? *
1 = Poor, 10 = Excellent
Do you trust your doctor (or clinical staff) to make decisions in your best interest? *
1 = Poor, 10 = Excellent
Does the doctor (or clinical staff) help you understand your condition? *
1 = Poor, 10 = Excellent
Does the doctor (or clinical staff) listen to you and answer your quesitons? *
1 = Poor, 10 = Excellent
Bedside manner / caring / communication *
1 = Poor, 10 = Excellent
Friendliness / courtesy / professionalism office staff *
1 = Poor, 10 = Excellent
Office environment - comfortable and clean? *
1 = Poor, 10 = Excellent
Diagnostic accuracy? *
1 = Poor, 10 = Excellent
Appropriate follow-up? *
1 = Poor, 10 = Excellent
Effective treatment? *
1 = Poor, 10 = Excellent
If you are a new patient, how did you hear about our practice?
Please select one.
May we have your consent to post your Scores and Comments on Internet rating sites? *
Many people rely upon the internet to provide them with information when making decisions. We want those using the internet to have reliable information about us; including our commitment to provide the highest level of service. With your consent, you are also providing limited power of attorney for MJS, Inc., the technology platform, to upload your Scores and Comments to internet sites.
May we use your name, initials or an alias when we post your comments to Internet rating sites? *
Please enter NAME, INITIALS or if you would like to use an "ALIAS" below. We will generate an alias for you.
Your answer
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