PATIENT SATISFACTION SURVEY
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WELCOME ... Your opinion matters!
We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for your time!
Survey:
Please let us know how well we are doing in the following areas:
How likely are you to recommend this company to a friend or colleague?
(lowest)
(highest)
Clear selection
Overall, how satisfied or dissatisfied are you with this organization?
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
Time in waiting room
Time in exam room
Waiting for tests to be performed
Waiting for test results
Clear selection
Staff: Provider (Physician, Dentist, Nurse Practitioner)
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
Listens to you
Takes enough time with you
Explains what you want to know
Gives you good advice and treatment
Clear selection
Nurses and Medical Assistants:
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
Friendly and helpful to you
Answers your questions
Clear selection
All Others:
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
Friendly and helpful to you
Answers your questions
Clear selection
Payment:
Yes
No
Were You informed of the Sliding Fee Discount Policy? 
Did you qualify for the Sliding Fee Discount?
Did you pay your Discount Nominal Fee?
Has the sliding fee scale created any financial barrier to care?
Clear selection
Facility:
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
Neat and clean building
Ease of finding where to go
Comfort and Safety while waiting
Clear selection
Privacy/Confidentiality:
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
Keeping my personal information private
Clear selection
Other:
GREAT-5
GOOD-4
OK-3
FAIR-2
POOR-1
The likelihood of referring your friends and relatives to us:
Clear selection
Do you consider this center your regular source of care?
Clear selection
Overall Satisfaction:
Clear selection
Thank you for completing our Survey!
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