Patient Satisfaction Survey

Submitted by roundbox on Fri, 10/08/2010 - 20:39

It is our goal to give you the best possible medical care. To do so, it is important that we know your thoughts about the care you are receiving. We need to know what we are doing right and in what areas we can improve. Your comments will be strictly confidential. Space is provided at the end of this survey for any additional comments you may wish to make. Thank you for your help.

Items marked with * are required.

Physician Name: *

Is this your: *

First visit, or

a return visit?

Why did you choose this office for your medical treatment?: *

Near my office or home

Referred by the Emergency Department

Referred by another patient

Telephone listing

Referred by another physician

Picked from my insurance plan physician listing

Other

How long did it take you to get in for your initial appointment?: *

Was this timeframe acceptable to you?:

Yes

Please describe your initial telephone call: *

The telephone was answered promptly

I was put on hold

I did not make the initial call

After you arrived how long did you have to wait to see your physician?: minutes

Did we provide you with helpful patient educational information?: *

Yes

N/A

If the physician was running behind, did the staff explain this to you?: *

Yes

N/A

Were your test results reported in a reasonable amount of time?: *

Yes

N/A

Did you receive adequate assistance in completion of any needed forms?: *

Yes

N/A

Would you refer a family member or friend to our office?: *

Yes

Please rate our practice in terms of:

	N/A	Poor	Fair	Good	Very Good	Excellent
The person who answered your call
How you were treated when you arrived at the reception desk
The nurse/assistant
The amount of time the doctor spent with you
The comfort of the waiting room
Your ability to contact us after hours
Your check-out experience
The provider’s interest in your problem
The provider’s explanation of your illness and treatment
The helpfulness of the individual helping with billing and/or insurance
The satisfaction of the medical treatment you received
The ease of use of the automated telephone system
Your experience with any x-ray or MRI procedures
What is your overall rating of our practice

Name (Optional):

Email Address (Optional):

Telephone Number (Optional):

Comments: