Patient Satisfaction Survey

Dear Patient: Our goal is to provide comfort, convenience, and satisfaction as well as the very best medical care to all our patients. We would like to know how you feel about our medical services, our patient-handling systems, and 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.

Please rate the following:
A. YOUR APPOINTMENT Excellent Very
Good
Good Fair Poor Does
Not
Apply
1. Ease of making appointments by phone
2. Appointment available within a reasonable amount of time
3. The efficiency of the check-in process
4. Waiting time in the reception area
5. Waiting time in the exam room
6. Ease of getting a referral when you needed one
             
B. OUR STAFF Excellent Very
Good
Good Fair Poor Does
Not
Apply
1. The courtesy of the person who took your call
2. The friendliness and courtesy of the receptionist
3. The caring concern of our nurses/medical assistants
4. The helpfulness of the people who assisted you with billing or insurance
5. The professionalism of our X-ray or MRI staff
             
C. OUR COMMUNICATION WITH YOU: Excellent Very
Good
Good Fair Poor Does
Not
Apply
1. Your phone calls answered promptly
2. Getting advice or help when needed during regular office hours
3. Explanation of your procedure (if applicable)
4. Your test results reported in a reasonable amount of time
5. Our ability to return your calls in a timely manner
6. Your ability to obtain prescription refills by phone
             
D. YOUR VISIT WITH THE PROVIDER:
    (Doctor, Nurse Practitioner)
Excellent Very
Good
Good Fair Poor Does
Not
Apply
1. Willingness to listen carefully to you
2. Taking time to answer your questions
3. Amount of time spent with you
4. Explaining things in a way you could understand
5. Instructions regarding medication/follow-up care
6. The thoroughness of the examination
             
E. OUR FACILITY: Excellent Very
Good
Good Fair Poor Does
Not
Apply
1. Hours of operation convenient for you
2. Overall comfort
3. Adequate parking
             
F. YOUR OVERALL SATISFACTION WITH: Excellent Very
Good
Good Fair Poor Does
Not
Apply
1. Our practice
2. The quality of your medical care
3. Overall rating of care from your provider or nurse
             
  Definitely
Yes
Probably
Yes

Don't
Know

Probably
Not
Definitely
Not
4. 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. PLEASE MARK THE APPROPRIATE ANSWER:

     
ARE YOU:  A new patient  A returning patient
     
GENDER:  Male  Female
     
YOUR AGE:  Under 18  41-50
   18-30  51-64
   31-40  65+

Thank you very much for your help!  
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