Patient Satisfaction Survey

1. How would you rate your experience with our Appointments telephone courtesy? *

2. How would you rate your experience with our Business Office telephone courtesy? *

3. How would you rate your experience with our Nursing Staff telephone courtesy? *

4. How would you rate our hours? *

5. How would you rate the amount of time you spent in the waiting room? *

6. How would you rate the amount of time you spent in the exam room? *

7. How would you rate the amount of time you spent with the doctor? *

8. How would you rate your experience with the front office staff (Check-In/Check-Out Desk)? *

9. How would you rate your experience with the nurse/medical staff? *

10. How would you rate your experience with the doctor? *

11. How would you rate our respect for your time/informing you of delays? *

12. How would you rate the appearance of our office? *

13. Overall, how would you rate the care and services provided from this office? *

14. If you could go anywhere for treatment, how likely are you to return to us? *

15. Which physician/care provider did you see? *

Date

Time * :

So that we have the opportunity to follow up with you if you have any concerns, we ask that you please provide your contact information below:

Name

First

Address

City

State/Province

Zip/Postal

Phone

Comments

Captcha