Patient Satisfaction Survey
We value the opinions of our patients and their families. Please take a few moments to complete this survey.
1. Scheduling appointments is easy and I am able to schedule for a time that is convenient for me
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
2. Wait times after checking in are reasonable and I am informed of any delays
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
3. Front desk staff is courteous and helpful
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
4. Medical Assistants are patient
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
5. Medical Assistants are knowledgeable
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
6. Doctors are kind
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
7. Doctors are knowledgeable
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
8. Staff spends enough time with me during my visit
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
9. All my concerns were addressed during my visit
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
10. I was given clear instructions on what to do about my condition or health
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
11. My privacy was respected
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
12. My billing or claim concerns were handled in a courteous and helpful manner
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
13. Office is clean and well-maintained
*
Strongly Agree
Agree
Neutral / No Opinion
Disagree
Strongly Disagree
14. Would you recommend our practice to a family member or friend?
*
Yes
No
Maybe
15. Overall how would you rate us?
*
1
2
3
4
5
Are there other suggestions or concerns you would like to share with us?
Do you have a positive experience you would like to share with us?
Would you like to be contacted by someone in our office?
*
Yes
No
If you wish to remain anonymous, it is not required to provide your information.
Name
Mr.
Mrs.
None
Prefix
First Name
Last Name
Phone Number
-
Area Code
Phone Number
E-Mail
example@example.com
Please verify that you are human
*
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