Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. All responses will be kept confidential and anonymous. Thank you for your time.

Physician seen in office:
Date of Visit:
How Long did you wait after your scheduled appointment time before you were seen?
Once in an exam room how long was the wait before the physician saw you?

Please check the appropriate box to tell us how well you think we are doing in the following areas

Scheduling
Timeframe between phone call & initial appointment:
Convenience of appointment times:
Satisfaction with the ease of making appointments:
Registration
Helpfulness of the person at the registration desk:
Waiting time before addressed at registration desk:
How would you rate this employee:
Our concern for your privacy:
Comments (describe good or bad experience):
Physician
Services you received from healthcare professional:
Courtesy/friendliness of physician:
Physicians concern for your care:
Physicians concern for your questions:
Comments (describe good or bad experience):
Secretary
Did you have to leave a voice mail?
Prompt return of phone calls:
Courtesy of the staff over the telephone:
Courtesy/friendliness of secretary:
How would you rate this employee:
Comments (describe good or bad experience):
Billing
Prompt return of phone calls:
Courtesy of the staff over the telephone:
Courtesy/friendliness of secretary:
How would you rate this employee:
Comments (describe good or bad experience):
Overall Assessment
Response to concerns/complaints made during visit:
Overall Rating of care during your visit:
Likeliness of your recommending our facility to others:
Comments (describe good or bad experience):
Patient Name (optional):