Patient Satisfaction Survey

Please take a few minutes to complete this survey. You can help us in our mission to provide our patients with the best care possible. Thank you for helping us find better ways to serve you.

If you wish to be contacted, please leave your name and contact information.

Name:

E-mail Address:

Phone Number:

Referring Doctor:

1. Were you seen as a patient the same day that you called our office?
Yes
No

2. Did you wait past your appointment time in our reception area?
Yes
No

If so, how long?
Less than 15 minutes
15-30 minutes
Over 30 minutes

3. Once you were seated in the treatment room, how long did you wait to see the doctor?
Less than 15 minutes
15-30 minutes
Over 30 minutes

For questions 4-7, please use the following scale:

-5 = Very Dissatisfied
-4
-3
-2 = Dissatisfied
-1
0 = Satisfied
+1
+2 = Very Satisfied
+3
+4
+5 = Extremely Satisfied

4. Courtesy shown over the phone.
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

5. Ease of scheduling your appointment initially.
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

6. Courtesy 6. Courtesy/friendliness shown by the reception staff.
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

7. Overall quality of the care you received today.
-5 -4 -3 -2 -1 0 +1 +2 +3 +4 +5

8. If we met or exceed your expectations during your visit today, tell us how:


9. If we did not meet your expectations during your visit today, tell us how we fell short: