Patient Satisfaction Survey
Please let us know about your recent experience at our office. Your survey response is anonymous and will be kept confidential. Any feedback you give will be used to improve our patient experience. Thank you for your time!
GENERAL INFORMATION
Please answer the following questions.
Your age:
Your gender:
Clear selection
Office location:
Procedure(s); please select all that apply:
How did you hear about us?
If you selected "Other" above, please let us know how you heard about us.
If you were referred to us by a doctor, what is his/her name?
EASE OF GETTING CARE
Please indicate how well we are doing in this area by answering the following questions.
Hours center is open:
Convenience of center's location:
Prompt return on phone calls:
WAITING
Please indicate how well we are doing in this area by answering the following questions.
Time in waiting room:
Time in exam room:
Waiting for tests to be performed:
STAFF
Please indicate how well we are doing in this area by answering the following questions.
Explanation of procedure and answering questions:
Respectful and courteous:
Friendly and helpful:
PAYMENT
Please indicate how well we are doing in this area by answering the following questions.
What you pay:
Explanation of charges:
Collection of payment:
FACILITY
Please indicate how well we are doing in this area by answering the following questions.
Neat and clean building:
Ease of finding where to go:
Comfort and safety while waiting:
Privacy:
CONFIDENTIALITY
Please indicate how well we are doing in this area by answering the following questions.
Keeping my personal information private:
Likelihood of referring your friends and relatives to us:
What do you like best about our center?
What do you like least about our center?
Suggestions for improvement:
If you’d like us to speak with us as a follow up to your survey, please leave a phone number or an email address where we can reach you directly. Thank you!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy