Patient Survey

    Name

    Email

    Please rate the following:

    A. YOUR APPOINTMENT:

    Ease of Making an Appointment
    PoorFairGoodVery GoodExcellentN/A

    The Efficiency of the Check-In Process
    PoorFairGoodVery GoodExcellentN/A

    Waiting Time in the Reception Area
    PoorFairGoodVery GoodExcellentN/A

    Waiting Time in the Exam Area
    PoorFairGoodVery GoodExcellentN/A

    B. OUR STAFF:

    The Friendliness and Courtesy of the Receptionist
    PoorFairGoodVery GoodExcellentN/A

    The Caring concern of our Nurses/Medical Assistants
    PoorFairGoodVery GoodExcellentN/A

    C. YOUR VISIT WITH THE PROVIDER:

    Willingness to Listen Carefully to You
    PoorFairGoodVery GoodExcellentN/A

    Taking Time to Answer your Questions
    PoorFairGoodVery GoodExcellentN/A

    Amount of Time Spent with You
    PoorFairGoodVery GoodExcellentN/A

    D. YOUR OVERALL SATISFACTION WITH:

    Our Practice
    PoorFairGoodVery GoodExcellentN/A

    The Quality of your Medical Care
    PoorFairGoodVery GoodExcellentN/A

    How did you Hear About our Office?
    Family/FriendInternetPrimary/Other DoctorRadioOther

    Would you Recommend the Provider to others?
    YesNo

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

    Are you:
    A New PatientA Returning Patient