Patient Survey
We are always striving to improve the care we provide. We would like to identify problems but also identify areas that we are doing well so we can acknowledge our staff. This form is anonymous. Please fill out the form as honestly as possible. Leave a question blank if it is not applicable to you. Thanks so much for helping us.
Was this your first visit with us?
How did you hear about us?
Did you have a chance to review our website prior to your visit?
If so, did you find the website helpful?
Do you have any comments on improving the website?
Your answer
Access to Care
Your answer
Ease of scheduling your appointment
Very Poor
Very Good
Our helpfulness on the telephone
Very Poor
Very Good
Courtesy of person who scheduled your appointment
Very Poor
Very Good
Our promptness in returning your phone calls
Very Poor
Very Good
Ability of getting an appointment for when you wanted
Very Poor
Very Good
Ease of getting through to the clinic on the phone
Very Poor
Very Good
Any comments about your access to care at our clinic?
Your answer
Your wait to see the doctor
Speed of the registration process during your visit
Very Poor
Very Good
Courtesy of staff in the registration area
Very Poor
Very Good
Comfort and pleasantness of the waiting area
Very Poor
Very Good
Length of wait before going to an exam room
Very Poor
Very Good
Comfort and pleasantness of the exam room
Very Poor
Very Good
Friendliness/courtesy of the nurse/assistant
Very Poor
Very Good
Concern the nurse/assistant showed for your problem
Very Poor
Very Good
Waiting time in exam room before being seen by the doctor
Very Poor
Very Good
Your answer
Degree to which you were informed about any delays
Very Poor
Very Good
Any comments about the front desk staff, waiting room or exam room wait, or our nursing staff?
Your answer
Dr. Jacobs
Friendliness/courtesy of Dr. Jacobs
Very Poor
Very Good
Explanations Dr. Jacobs gave you about your problem or condition
Very Poor
Very Good
Concern Dr. Jacobs showed for your questions or worries
Very Poor
Very Good
Dr. Jacobs' efforts to include you in decisions about your treatment
Very Poor
Very Good
Information Dr. Jacobs gave you about medications (if any)
Very Poor
Very Good
Instructions Dr. Jacobs gave you about follow-up care (if any)
Very Poor
Very Good
Degree to which Dr. Jacobs talked with you using words you could understand
Very Poor
Very Good
Amount of time Dr. Jacobs spent with you
Very Poor
Very Good
Your confidence in Dr. Jacobs
Very Poor
Very Good
Likelihood of your recommending Dr. Jacobs to others
Very Unlikely
Very Likely
Comments about Dr. Jacobs (good or bad)?
Your answer
Ancillary Services
Courtesy of lab technician
Very Poor
Very Good
Any comments about our lab (good or bad)?
Your answer
Courtesy of skin testing technician
Very Poor
Very Good
Courtesy of pulmonary function and/or exhaled nitric oxide technician
Very Poor
Very Good
Any comments about our skin testing or pulmonary function services?
Your answer
Courtesy of infusion nurse
Very Poor
Very Good
Any comments about our infusions (good or bad)?
Your answer
Allergy shots
Length of wait before getting an allergy injection
Very Poor
Very Good
Courtesy of the staff giving you your injection
Very Poor
Very Good
Your comfort level with the staff giving you your injection
Very Poor
Very Good
Ability to receive an allergy injection at a time convenient for you
Very Poor
Very Good
Would you rather have a walk-in clinic for allergy injections (might increase wait time but you could come whenever during a set time) or an appointment time for the injection (decreased wait time but less flexibility)?
Overall satisfaction with our allergy shot clinic?
Very Unsatisfied
Very Satisfied
Any comments (good or bad) about our allergy shot clinic?
Your answer
Personal Issues
Convenience of our office hours
Very Poor
Very Good
Our sensitivity to your needs
Very Poor
Very Good
Our concern for your privacy
Very Poor
Very Good
Ease of obtaining test results
Very Poor
Very Good
Comments (good or bad)?
Your answer
Billing
Promptness with which questions or problems about your bill were resolved (if you had any)
Very Poor
Very Good
Handling of insurance/billing questions
Very Poor
Very Good
Courtesy of insurance/billing personnel
Very Poor
Very Good
Comments (good or bad)?
Your answer
Overall Assessment
Overall cheerfulness of our practice
Very Poor
Very Good
Overall cleanliness of our practice
Very Poor
Very Good
Overall rating of care received during your visit
Very Poor
Very Good
Likelihood of your recommending The Center for Allergy & Immunology to others
Very Unlikely
Very Likely
Comments (good or bad)?
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service