Patient Satisfaction Survey

Patient Satisfaction Survey

Please take a few moments to complete this survey
Name: (Optional)

First Name Last Name
Physician
Location?
Are you?

A New Patient A Returning Patient
Gender
Birth Date

Month Day Year
Date Of Service

Month Day Year

Overall satisfaction

	Excellent	Very Good	Good	Fair	Poor	Does Not Apply
Ease of making appointments by phone
Appointment available within a reasonable amount of time
Getting care for illness/injury as soon as you wanted it
Getting after-hours care when you needed it
The efficiency of the check in process
Waiting time in the reception area
Waiting time in the exam room
Keeping you informed if your appointment time was delayed
Ease of getting a referral when you needed one
The courtesy of the person who took your call
The friendliness and the courtesy of the receptionist
The caring concern of our nurses/medical assistants
The helpfulness of the people who assisted you with your billing or insurance
The professionalism of our lab
Your phone calls are answered promptly
Getting advice or help when needed during office hours
Explanation of your procedure (if applicable)
Your test results reported in a reasonable amount of time
Effectiveness of our health information materials
Our ability to return your calls in a timely manner
Your ability to contact us after hours
Your ability to obtain prescription refills by phone
Physician willingness to listen carefully to you
Physician taking time to answer your questions
Physician amount of time spent with you
Explaining things in a way you could understand
Instructions regarding medication/follow-up care
Physician thoroughness of the examination
Advice given to you on ways to stay healthy
Hours of operation convenient for you
Overall comfort
Adequate parking
Signage and directions easy to follow
The quality of your medical care
Overall rating of care from your doctor or nurse

How can we improve our service?
What is your overall satisfaction with our Practice?
Would you recommend us? If No, Why?
Is there any member of our staff you would like to praise or mention?
Would you like to be contacted regarding this survey?

Yes No
Please leave your phone number here if yes.
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