Patient Survey

 

Name (optional):
Visit Date:
Location:
Appointment Scheduling  No Opinion  Poor  Fair  Good Excellent
Efficiency of our phone system?
I received prompt and courteous service.
My appointment was scheduled within an acceptable timeframe.
Front Office / Reception Staff  No Opinion  Poor  Fair  Good Excellent
Upon my arrival, I was greeted in a courteous and timely manner.
The registration process was quick and easy.
I waited an acceptable amount of time to see the provider.
Appearance of the facility  No Opinion  Poor  Fair  Good Excellent
The waiting room was clean with a pleasant decor.
The exam room was clean.
Clinical Staff  No Opinion  Poor  Fair  Good Excellent
The nurse and clinical staff were courteous and professional.
The staff showed concern for my problems.
Consideration was given to my privacy.
Providers: Physician, Physician Assistant, Nurse Practitioner  No Opinion  Poor  Fair  Good Excellent
The provider clearly explained my problem, condition and/or procedure.
The provider showed respect for my questions.
The provider was professional and friendly.
Other Questions  No Opinion  Poor  Fair  Good Excellent
How was our promptness in returning your calls?
How likely are you to recommend our services to others?
Does our website meet your needs?

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