Patient Survey

PATIENT SATISFACTION SURVEY

In order to serve you better, please take a moment to complete this survey. Your feedback is confidential. Thank you for participating. *Required

5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor, N/A = Does Not Apply

General Information
Full Name (If you wish to remain anonymous, input "Anonymous")
Email Address* (Insert a fictitious email if you want to remain anonymous.)
1. Your Appointment was with:*
2. Your Age:*
3. Are you a:

Your Appointment
1. Ease of making appointments by phone	5 4 3 2 1 N/A
2. Appointment available within a reasonable amount of time	5 4 3 2 1 N/A
3. Getting care of illness/injury as soon as you wanted it	5 4 3 2 1 N/A
4. Getting after-hours assistance when you needed it	5 4 3 2 1 N/A
5. The efficiency of the check-in process	5 4 3 2 1 N/A
6. Waiting time in the reception room	5 4 3 2 1 N/A
7. Waiting time in the exam room	5 4 3 2 1 N/A
8. Keeping you informed if your appointment time was delayed	5 4 3 2 1 N/A

Our Staff
1. The courtesy of the person who took your call	5 4 3 2 1 N/A
2. The friendliness and courtesy of the receptionist	5 4 3 2 1 N/A
3. The caring concern of our nurses/medical assistants	5 4 3 2 1 N/A
4. The helpfulness of the people who assisted you with billing or insurance	5 4 3 2 1 N/A

Our Communications
1. Your phone calls answered promptly	5 4 3 2 1 N/A
2. Getting advice or help when needed during office hours	5 4 3 2 1 N/A
3. Explanation of your procedure (if applicable)	5 4 3 2 1 N/A
4. Your test results reported in a reasonable amount of time	5 4 3 2 1 N/A
5. Effectiveness of our health information materials	5 4 3 2 1 N/A
6. Our ability to return your calls in a timely manner	5 4 3 2 1 N/A
7. Your ability to contact us after hours for urgent concerns	5 4 3 2 1 N/A
8. Your ability to obtain prescription refills by phone	5 4 3 2 1 N/A

Your Visit With Us
1. Willingness to listen carefully to you	5 4 3 2 1 N/A
2. Taking time to answer your questions	5 4 3 2 1 N/A
3. Quality of time spent with you	5 4 3 2 1 N/A
4. Explaining things in a way you could understand	5 4 3 2 1 N/A
5. Instructions regarding medication/ follow-up care	5 4 3 2 1 N/A
6. The thoroughness of the examination	5 4 3 2 1 N/A
7. Advice given to you on ways to stay healthy	5 4 3 2 1 N/A

Our Facility
1. Hours of operation convenient for you	5 4 3 2 1 N/A
2. Overall comfort	5 4 3 2 1 N/A
3. Adequate parking	5 4 3 2 1 N/A
4. Signage and directions easy to follow	5 4 3 2 1 N/A

Your Overall Satisfaction
1. Our practice	5 4 3 2 1 N/A
2. The quality of your medical care	5 4 3 2 1 N/A
3. Overall rating of care from your provider or nurse	5 4 3 2 1 N/A

Misc.
1. Would you recommend the provider to others? Yes No If not, please tell us why?

2. What other services would you like to see us provide?

3. If there is any way we can improve our services to you, please tell us about it:

External Links

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PATIENT SATISFACTION SURVEY

5 = Excellent, 4 = Very Good, 3 = Good, 2 = Fair, 1 = Poor, N/A = Does Not Apply

General Information

Your Appointment

Our Staff

Our Communications

Your Visit With Us

Our Facility

Your Overall Satisfaction

Misc.

External Links

Pay Invoice

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