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Welcome to our Post-Visit Satisfaction Form!
We appreciate you taking the time to take our survey. We will use this form to make changes to better serve you. Please fill out all areas to the best of your ability.
16
Questions
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1
Name
First Name
Last Name
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2
Which location did you visit?
Raleigh
Wilmington
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3
What service did you have completed that you would like to leave feedback on?
Please add your provider's name, if applicable.
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4
Overall, how would you rate the service you received from the staff at our office?
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Excellent
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5
Overall, how satisfied or dissatisfied were you with your last visit to our office?
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6
How easy or difficult was it to schedule your appointment at a time that was convenient for you?
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Very difficult
Very easy
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7
In your opinion, how convenient is the location of our office?
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Not at all convenient
Very convenient
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8
How comfortable was the lobby and waiting area?
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9
How likely is it that you would recommend your provider to a friend or family member?
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Not at all likely
Extremely likely
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10
Did your appointment with your provider start early, late or on time?
Very Early
Somewhat early
On time
Somewhat late
Very late
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11
How much do you trust your provider to make medical decisions that are in your best interests?
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I do not trust him/her
I completely trust him/her
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12
How well did your provider take the time to listen to your needs and answer your questions?
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Not well
Extremely well
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13
How well did your provider explain your treatment options?
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Not well
Extremely well
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14
How well did your provider explain your follow-up care?
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Did not go over at all
Extremely well
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15
Is there anything we could have done to improve your last visit?
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16
Email
Please provide your email if you would like a client service representative to reach out to you in regards to your recent experience with us.
example@example.com
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