Patient Satisfaction Survey

The following short survey is designed to gauge your satisfaction with your appointment, our staff, and the overall visit and treatment. Your answers will be held in complete confidence, and will be used by us to help better serve our patients in the future.

Patient Satisfaction Survey Sections or fields marked * are required

Physician you were treated by *

PLEASE RATE THE FOLLOWING:

A. YOUR APPOINTMENT *

		Excellent	Very Good	Good	Fair	Poor	N/A
1.	Ease of making appointments
2.	Appointment availability times
3.	The efficiency of our check-in process
4.	Waiting time in the reception area
5.	Ease of getting your referrals from our referral coordinator

B. OUR STAFF *

		Excellent	Very Good	Good	Fair	Poor	N/A
1.	The courtesy of the person who took your call
2.	The friendliness and courtesy of the receptionist
3.	The friendliness and concern of our medical assistants
4.	The helpfulness of the people who assisted you with billing or insurance

C. OUR COMMUNICATION WITH YOU *

		Excellent	Very Good	Good	Fair	Poor	N/A
1.	Your phone calls answered promptly/calls returned in a timely manner
2.	Getting advice or help when needed during office hours
3.	Explanation of your surgical procedure (if applicable)

D. YOUR VISIT WITH THE PROVIDER (Doctor, Physician Assistance, Nurse Practitioner) *

		Excellent	Very Good	Good	Fair	Poor	N/A
1.	Willingness to listen carefully to you
2.	Taking time to answer your questions
3.	Explaining things in a way you could understand
4.	Instructions regarding medication/follow-up care
5.	Advice given to you on ways to stay healthy

E. OUR FACILITY *

		Excellent	Very Good	Good	Fair	Poor	N/A
1.	Hours of operation
2.	Overall comfort/Cleanliness of our office
3.	Parking
4.	Signage and directions easy to follow

F. YOUR OVERALL SATISFACTION WITH *

		Excellent	Very Good	Good	Fair	Poor	N/A
1.	Our practive
2.	The quality of your medical care
3.	Overall rating of care from your provider or nurse

WOULD YOU RECOMMEND THE PROVIDER TO OTHERS? *

IF NO, PLEASE TELL US WHY:

IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

SOME INFORMATION ABOUT YOU:

I am	*
My gender	*
My age	*

Your name	(Optional)
Your email address	(Optional - Kept Confidential)

WOULD YOU LIKE TO PROVIDE A TESTIMONIAL FOR OUR WEBSITE/MARKETING MATERIALS?

Please enter the code to continue
	*