Patient Survey

We thank you in advance for completing this questionnaire.  We use your feedback to evaluate our services.

A. Access To Care

1. Ease of scheduling your appointment
2. Courtesy of person who scheduled your appointment
3. Our promptness in returning your phone calls
Please list name of person you are trying to reach:
Comments:

B. During Your Visit

1. Speed of the registration process
2. Courtesy of staff in the registration area
3. Length of wait before going to an exam room
4. Friendliness/courtesy of the nurse/assistant
5. Waiting time in exam room before being seen by the care provider
Comments:

C. Your Care Provider

1. Friendliness/courtesy of the care provider
2. Concern the care provider showed for your questions or worries
3. Degree to which care provider talked with you using words you could understand
4. Amount of time the care provider spent with you
5. Likelihood of your recommending this care provider to others
Comments:

D. Overall Assessment

1. Overall cheerfulness of our practice
2. Overall cleanliness of our practice
3. Our concern for your privacy
How could we improve our service to you?

Background Information

Physician's Name:
Date of Visit:
Name of person completing survey (optional):
Patient's name (optional):
Address (optional):
Telephone Number (optional):