Patient Satisfactory Survey Form
We at Abik Healthcare Services are committed to delivering the highest quality care to our patients and their families. Periodically, we review and update certain procedures in order to provide quality of care. Our staff is licensed by the State of Maryland, which we verify during the pre-employment process. We provide our staff with ongoing educational training.
Did the clinician(s) begin services on the requested date?
Yes
No
Did the clinician(s) schedule visits in advance and adhere to the schedule?
Always
Sometimes
Never
Did the clinician(s) arrive on time for the visit?
Yes
No
If late, did the clinician(s) call to notify you.
Yes
No
Did the clinician(s) inform you of the HIPAA privacy act and bill of right on admission?
Yes
No
Did the clinician(s) inform you of the compliant process and state hotline number?
Yes
No
Overall, how would you rate our clinician?
Rows
Very Satisfied
Satisfied
Neutral
Dissatisfied
Very Dissatisfied
Nurse
Physical Therapist
Occupational Therapist
Speech Therapist
Office Staff
Other
Were you and your family treated with respect and courtesy?
Yes
No
If No, please explain
Would you recommend our agency to family / friends?
Yes
No
Do you have any compliments or complaints?
Any other comments or feedback
Patient Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature (optional)
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Should be Empty: