Satisfaction Survey

Dear Patient:

Would you take a few minutes of your time to help us? Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all our patients. We'd like to know how you feel about our medical services, our patient-handling systems, our physicians and staff members. Your comments will help us evaluate our operations to ensure that we are truly responsive to your needs.

Thank you for your help.

HOW SATISFIED ARE
YOU WITH:		 Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
YOUR APPOINTMENT:
1. Appointment available within a reasonable amount of time
2. Appointment scheduled at a convenient time of day
3. Waiting time in the reception area
4. Waiting time in the exam room

OUR STAFF: Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
5. The friendliness and courtesy of our receptionists
6. The caring concern of our nurses
7. The helpfulness of the people in our business office
8. The professionalism of our technical staff

OUR COMMUNICATION
WITH YOU:		 Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
9. Your phone calls answered promptly
10. Availability of medical information/advice by telephone
11. Explanation of your test procedure (if applicable)
12. Your test results reported in a reasonable amount of time
13. Effectiveness of our health information materials
14. The doctor returning your calls in a timely manner

YOUR VISIT WITH
THE DOCTOR:		 Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
15. The doctor listening to you
16. The doctor taking time to answer your questions
17. The doctor adequately explaining treatment options
18. The thoroughness of the examination
19. Amount of time the doctor spent with you
20. The outcome of treatment prescribed by your doctor

OUR FACILITY: Very
Satisfied		 Somewhat
Satisfied		 Somewhat
Dissatisfied		 Very
Dissatisfied		 Not
Applicable
21. Hours of operation convenient for you
22. Overall comfort
23. Adequate parking
24. Signage and directions easy to follow

 
OVERALL RATING

Excellent Good Fair Poor
Our Practice
The Quality Of
Your Medical Care

 

WOULD YOU RECOMMEND OUR PRACTICE
TO A FAMILY MEMBER OR FRIEND?
Yes No

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


Your name/telephone number (optional):


Your email address (optional):


Your doctor:


Thank you for your help!