Patient Satisfaction Survey
Dear Patient: As part of our ongoing efforts to provide the highest quality service to our patients we are very interested in receiving your feedback about the care you received from our office. Please take a few minutes to complete this survey and return it to us. Your response is very important to us. Your answers will be kept confidential and all results will be aggregated and utilized to improve patient care. Thank you in advance for your help.
1. ACCESS TO THE CLINIC *
Very Satisfied
Satisfied
Not Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
Ease of making your appointment by telephone
Ability to get an appointment as quickly as you wanted it
Ability to be seen on the day and time that works best for you
The time that you spent in the waiting room and exam room before seeing your doctor
2. OUR STAFF *
Very Satisfied
Satisfied
Not Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
The friendliness of the front desk staff
The caring and concern of the nurses/medical assistants
3. COMMUNICATION *
Very Satisfied
Satisfied
Not Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
The speed with which your telephone calls are answered
Your ability to get help or advice during office hours by telephone
The way your doctor listened to your concerns and showed understanding of your health condition
Your doctor’s explanation of things in a way you could understand
Ease of understanding instructions regarding your medication and follow-up care
The availability of your health information, such as test results
4. CARE COORDINATOR *
Very Satisfied
Satisfied
Not Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
Your doctor’s communication with other providers involved in your care
Your doctor’s efforts to involve you in planning your own care
Your doctor’s use of a patient centered approach to your care
The quality and ease of use of the self-management tools given to you by the practice
5. OVERALL SATISFACTION *
Very Satisfied
Satisfied
Not Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
How satisfied are you with our practice overall
6. LIKELIHOOD TO RECOMMEND *
Very Satisfied
Satisfied
Not Satisfied or Dissatisfied
Dissatisfied
Very Dissatisfied
Does Not Apply
How likely are you to recommend our practice to your friends and family
7. Please let us know the reasons you would or would not recommend our practice to others. *
Your answer
8. Please let us know if there is anything we can do to improve our services to you. *
Your answer
9. Gender: *
10. Age: *
11. Primary Language *
12. Do you have health insurance *
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