Name (Optional)
First Name
Last Name
Date of your visit
-
Month
-
Day
Year
The amount of time it took for the initial process of signing in and filling out paperwork.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The receptionist immediately greeted patient upon arrival.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The receptionist informed the patient of delays.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The amount of time patient waited in the exam room.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The nursing staff kept patient informed of any delays while waiting in the exam room.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The cleanliness of the office.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The amount of time it took to check out and make a follow up appointment (if applicable).
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
The staff is friendly, cheerful and accommodating.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
Overall experience.
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
Any suggestions for improvement?
Is there a specific employee whom you would like to see congratulated or thanked for the care he/she provided during your visit at this office?
Based on your experience at this office, would you recommend a family member or friend?
Yes
No
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