Patient Info

Patient Satisfaction Survey

Please take a moment to tell us how we did

Name (Optional)

What's your age?

Gender

Please select your date of service:

Are you a new patient?

Which office location was your visit at?

Who was your Provider?

Please rate how well we are doing in the following Areas:

Our Facility

Office Hours:

Your appointment being scheduled within a reasonable time:

The convenience to our office locations:

The ease of our signage and directions:

Additional Facility Comments:

Waiting Area

With the waiting time in our waiting room and/or exam room:

With our amenities offered in our waiting area:

Additional Waiting Area Comments:

OUR STAFF'S PROFESSIONALISM, COURTEOUSNESS AND EFFICIENCY

With our call center when scheduling your appointment:

With our registration staff:

With our Medical Assistant/Nurse intake process:

With your providers Medical Secretary:

With the check-out process:

With our staff when calling for prescriptions, test results, billing or any other questions:

Additional Comments: (Feel free to highlight any positive or negative employee experience you may have had)

PROVIDER (Physician, Nurse Practitioner, or Physician’s Assistant)

With obtaining the proper dignity and respect from your provider:

With the ability to ask questions to your provider:

With the amount of time spent with your provider:

With instructions regarding medication/follow–up care:

With the clarity of explanation/answers from your provider:

Additional Provider Comments:

Our Communication with you

With the effectiveness of our health information, instructions and hand-outs:

With the ability to return your calls in a timely manner:

With getting advice or help during office hours:

With getting advice or help after office hours:

Additional Communication Comments:

Confidentiality

With us obtaining/keeping your confidentiality:

Additional Confidentiality Comments:

If there is one thing you could choose to improve our services, what would that one thing be:

What would you tell your friends and family about our practice and services:

For your health