Clone of Patient Satisfaction Survey | Michael W Goodman MD PC

Name (Optional)

First NameLast Name
Date of your visit

MonthDayYear
2 digit month, 2 digit day, 4 digit year
The amount of time it took for the initial process of signing in and filling out paperwork.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
The kindness shown by the patient care staff.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
The explanation of the Prep and procedure instructions.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
The staff's respect for patient's privacy.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
The staff informing the patient of any delays in care and/or treatment.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
The amount of time waiting at the facility.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
The cleanliness of the facility.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Discharge instructions explained clearly.

1

2

3

4

5

1 is Very Dissatisfied, 5 is Very Satisfied
Overall experience.

1

2

3

4

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?
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