Patient Satisfaction Survey
Dear Patient,

We are interested in finding out how you feel about various aspects of my office practice. Please take a moment to complete this questionnaire about your recent visit to my office. Your responses are confidential and are greatly appreciated. Thank you.

Please rate each of the following:

The accessibility of the office. (Is the office easy to find, are stairs or elevators readily available, is handicapped entrance adequate, etc.)
The comfort of the reception area
The comfort of the examining room
The cleanliness of the office, including the reception area and examination room.
The promptness with which our telephones are answered.
The wait time to see the provider
The ease of making an appointment
The courtesy of the staff
The amount of time spent with your physician
The quality of care you received
The privacy of the physician's consultation room and the examination room
Overall, how would you rate your experience?
Do you have any suggestions for improving the reception are?
Your answer
Do you have any additional comments?
Your answer
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