Patient Survey
 
Patient Survey -Physician Survey
** All Comments Will Remain Confidential **
     
Name: (Optional)
Which facility were you seen at?
 Appointment date:
  Select the number best corresponding with your experience:
1=Excellent
2=Good
3=Fair
4=Poor
  
  Tell us your opinion on getting an appointment:
 
 

Ease of getting through on the phone:
1
2
3
4
 
 

Courtesy and helpfulness of appointment secretary:
1
2
3
4
 
 

Getting an appointment at the time you wanted:
1
2
3
4
 
  Tell us your opinion on our practice:
 
  Courtesy and helpfulness of front desk staff:
1
2
3
4
 
  Explanation of registration forms:
1
2
3
4
 
  Explanation of billing procedures:
1
2
3
4
 
  Wait time in the reception area:
1
2
3
4
 
  How long did you wait in the reception area?
 
  Courtesy and helpfulness of nurse (if applicable):
1
2
3
4
 
  Courtesy and helpfulness of doctor (if applicable):
1
2
3
4
 
  Did any staff provide exceptional service?
 
  Rate the technologist you saw:
 
  Taking enough time with you:
1
2
3
4
 
  Giving you the information you needed about the exam:
1
2
3
4
 
  Being careful and helpful:
1
2
3
4
 
  Tell us your opinion on our facility:
 
  Convenient location:
1
2
3
4
 
  Cleanliness, appearance of office:
1
2
3
4
 
  Signs helpful in finding where to go:
1
2
3
4
 
  Dressing area clean, comfortable and private:
1
2
3
4
 
  Would you recommend our facility to others:
Yes:
No:
 
  Reason for using facility:
 
 
Convenience Doctor's choice Personal experience
Recommendation from friend Advertisement Other
  If you have received bills, give us your feedback:
 
  Easy to understand monthly bills:
1
2
3
4
 
  Courtesy and helpfulness of billing staff:
1
2
3
4
 
 

Submit any other comments:

  
 
         
   
 

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