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?
Your answer
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
How acceptable was the time you waited in the waiting room? *
1 = Logest, 10 = Shortest
Does the doctor (or clinical staff) listen to you and answer your questions? *
1 = Poor, 10 = Excellent
Friendliness / courtesy / professionalism office staff *
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 authorization 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. Note: You are in the driver's seat with your choice to provide authorization. Your choice will not affect treatment. If any information is sent to such Internet rating and review sites pursuant to your authorization, as it is online, it may no longer be protected by HIPAA. With your authorization, you are also providing limited power of attorney for MJS, Inc., the technology platform, to upload your Scores and Comments to select sites. This authorization will remain valid for one year unless revoked by notifying the practice in writing.
Complete 1 of the 3 options, below. May we use your name, initials or an alias when we post your comments to an Internet rating site? *
Option 1: Please provide your first and last name.
Your answer
Option 2: Please provide your initials.
Your answer
Option 3: Please provide an alias.
Your answer
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