Satisfaction Survey
1. Did you have trouble locating our office?
Yes
No
1a. If yes, please explain:
2. When I called the office during regular office hours, I received the help or advice I needed.
Yes
No
3. If I had to leave a message, I received a call back that same day.
Yes
No
3a. If no, What was the unreturned call regarding?
4. The
front office
staff met and greeted me promptly and courteously.
Yes
No
5. The
nursing
staff greeted me promptly and courteously.
Yes
No
6. The nurses spent an appropriate amount of time with me to understand and communicate my medical needs.
Yes
No
7. How long did you have to wait to see the provider?
8. The provider listened to me and my problems and showed respect and concern for what I had to say.
Yes
No
9. The provider explained things in a way I could understand.
Yes
No
10. The provider spent enough time with me at this visit to discuss the problem I came in for.
Yes
No
11. Which provider(Doctor) did you see?
12. When I checked out, the staff member collected my payment, or explained the insurance billing if needed.
Yes
No
13. If I received a referral to a specialist at my visit, it was handled in a timely manner and to my satisfaction.
Yes
No
14. I was satisfied with how quickly the office was able to arrange an appointment for me.
Yes
No
15. I would recommend your facility to others.
Yes
No
16. The rating I would give the staff and the provider for this visit at your facility:
Poor
Fair
Good
Excellent
17. My insurance company is:
18. How would you rate your insurer?
Poor
Fair
Good
Excellent
Additional Comments and/or Suggestions:
Full Name:
Email:
