Patient Satisfaction Survey
Is this your first time in our facility?
Yes
No
When you called for an appointment, how would you rate the response from the person who answered the telephone?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
When you arrived at the office, how would you rate the receptionist(s) in the following areas: Friendly, Helpful, and Courteous?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How acceptable was the amount of time spent in the reception area and exam room before seeing the doctor?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
When you were called to the exam room, how would you rate our staff in the following areas: Friendly, Competent, and Professional?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
During your examination, how would you rate the doctor in the following areas: Friendly, Competent, and Professional?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
When you saw the doctor, how would you rate the amount of time he/she spent with you, answering your questions, and explaining your diagnosis and treatments to your satisfaction?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
If treatment was recommended, how satisfied were you with the information provided by the doctor/staff regarding your treatment and follow-up care?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
When asking payment questions, how would you rate our staff in the following areas: Friendly, Helpful, and Courteous?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
By considering overall experience with our facility, how likely would you recommend to your friends/family?
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Please share any comments/suggestions
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