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Patient Satisfaction Survey

We would like to know how you feel about the services we provided so we can make sure we are meeting your needs. Your responses are important to us and will help us improve the services we offer. All responses are confidential and anonymous. Thank you for your time!

Date of your visit:
Which member of our team provided the majority of your care:





The person completing this survey was:



Please tell us the age of the patient:
Please tell us the age of the person completing this survey:
What is the gender of the patient:



What is the gender of the person completing this survey:




Please tell us how we did in each of the following areas:
Ease of getting care
Great
Good
OK
Fair
Poor

 

Ability to get in to be seen

 

Hours we are open

 

Convenience of office location

 

Prompt return of calls
Waiting          

 

Time in waiting room

 

Time in exam room

 

Waiting for tests to be performed

 

Waiting for test results
Staff          

Physician/Physician Assistant

Great
Good
OK
Fair
Poor

 

Listens to you

 

Takes enough time with you

 

Explains diagnosis and treatment

 

Gives you good advise and treatment
Nurses and Medical Assistants          

 

Friendly and helpful

 

Answers your questions
All other office staff
Great
Good
OK
Fair
Poor

 

Friendly and helpful

 

Answers your questions
Payments

 

What to pay

 

Explanation of charges

 

Collection of payment
Facility
Great
Good
OK
Fair
Poor

 

Neat and clean

 

Ease of parking

 

Comfort while waiting

 

Privacy
Confidentiality          

 

Keeping my personal information private
Likelihood of referring family and friends to us?
What do you like best about our office:
What do you like least about our office:
Suggestions for improvement:

If you would like a personal response to your comments, please provide your email address. (Please note: If you provide your email address your responses will no longer be anonymous but will still be kept confidential):
 


Enter Above Characters:

Thank you for taking our survey!