We appreciate your honesty and plan to evaluate each survey so as to improve the quality of care we provide to our patients. Thank you for completing this survey
What doctor are you seeing today?
Today's Date
Are you a new patient today?
Yes
No
Have you ever referred someone to us?
Yes
No
Availability
Ease of scheduling your appointment:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Ease of usinge our telephone system:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Courtesy of person who scheduled your appointment:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Helpfulness of staff on telephone:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Office's timeliness in returning your calls:
Please Select
Excellent
Good
Fair
Poor
Very Poor
While You Were At Our Office
Ease of registration process:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Time spent waiting to be registered:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Friendliness of front desk staff:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Comfort of waiting area:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Time spent waiting before going to exam room:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Comfort of exam room:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Courtesy of nurse and/or medical assistant:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Sensitivity of nurse/medical assistant towards your visit:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Time spent waiting in exam room for provider:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Your Physician
Friendliness/courtesy of your healthcare provider:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Explanations about your visit, or health problem:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Concern provider showed for your questions or worries:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Did the provider include you in decisions about your treatment:
Please Select
Yes
No
Information provider gave you about your medications:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Instruction provider gave you about follow-up:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Provider spoke to you using language you understood:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Amount of time provider spent with you:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Your confidence in this provider:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Probability you would recommend this provider:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Overall Rating
Overall rating of care you received during your visit:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Overall cleanliness of office:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Our awareness and understanding of your needs:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Availability/accessibility of our office hours:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Our concern for your privacy:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Probability you would recommend our office:
Please Select
Excellent
Good
Fair
Poor
Very Poor
Are there any other services you would like to see us provide?
Was there any particular staff member helpful?
Your Contact Information (optional)
Your Name:
Your Email:
Your Phone:
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