Patient Satisfaction Survey

1. How would you rate your experience with our telephone courtesy?
Excellent
Very Good
 Good Fair Poor

2. How would you rate our hours?
Excellent
Very Good
 Good Fair Poor

3. How would you rate the amount of time you spent in the waiting room?
Excellent   Very Good Good Fair Poor

4. How would you rate the amount of time you spent in the exam room?
Excellent   Very Good Good Fair Poor

5. How would you rate the amount of time you spent with the doctor?
Excellent   Very Good Good Fair Poor

6. How would you rate your experience with the front office staff (Check-In Desk)?
Excellent   Very Good Good Fair Poor

7. How would you rate your experience with the nurse/medical staff (Check-Out Desk)?
Excellent   Very Good Good Fair Poor

8. How would you rate your experience with the nurse/medical staff?
Excellent   Very Good Good Fair Poor

9. How would you rate your experience with the doctor?
Excellent    Very Good Good Fair Poor

10. How would you rate our respect for your time/informing you of delays?
Excellent   Very Good Good Fair Poor

11. How would you rate the appearance of our office?
Excellent   Very Good Good Fair Poor

12. Overall, how would you rate the care and services provided from this office?
Excellent Very Good Good Fair Poor

13. If you could go anywhere for treatment, how likely are you to return to us?
Very Likely Likely Maybe Unlikely Very Unlikely

OPTIONAL INFORMATION:

First Name:
Last Name:
Address:
City:
State:
Zip Code:
Phone Number:
Email Address:

 
 

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