GDE Post-Visit Survey

1

Name* This field is required.

First Name

Last Name

2

Would you recommend us to others? * This field is required.

YESNO

3

What did you enjoy about your visit?

4

We’re sorry your experience was less than perfect. Please share what you experienced that made you feel this way and any suggestions on how we can improve.

5

How well did your provider explain your treatment plan and next steps?* This field is required.

Very Well

Well

Neutral

Poorly

6

How can we improve?

7

How satisfied are you with the friendliness and professionalism of our staff?* This field is required.

Very Satisfied

Satisfied

Neutral

Unsatisfied

8

How can we improve?

9

What did we see you for today?* This field is required.

Weight Management

Endocrine Management

Diabetes Management

All of the Above

Other

10

How long have you been a patient with us?* This field is required.

Less than 6 months

6 months to 1 year

1-5 years

5+ years

13

How comfortable and safe did you feel today?* This field is required.

Very Comfortable

Comfortable

Neutral

Uncomfortable

14

What would make you feel more comfortable and safe?

15

What did you like most about your visit? * This field is required.

16

How did our team or clinician make your experience positive? * This field is required.

18

How did you schedule your appointment?* This field is required.

Phone

Website Form

Online Patient Portal

Other

19

· How would you rate your appointment scheduling process?* This field is required.

Excellent

Good

Fair

Poor

20

· Did our team answer all your questions?* This field is required.

YESNO

22

Phone Number

Area Code

Phone Number

23

Email

example@example.com

24

Zipcode