Patient Satisfaction Survey Patient Satisfaction Survey 1. How would you rate your experience with our Appointments telephone courtesy? Excellent Very Good Good Fair Poor N/A 2. How would you rate your experience with our Business Office telephone courtesy? Excellent Very Good Good Fair Poor N/A 3. How would you rate your experience with our Nursing Staff telephone courtesy? Excellent Very Good Good Fair Poor N/A 4. How would you rate our hours? Excellent Very Good Good Fair Poor N/A 5. How would you rate the amount of time you spent in the waiting room? Excellent Very Good Good Fair Poor N/A 6. How would you rate the amount of time you spent in the exam room? Excellent Very Good Good Fair Poor N/A 7. How would you rate the amount of time you spent with the doctor? Excellent Very Good Good Fair Poor N/A 8. How would you rate your experience with the front office staff (Check-In Desk)? Excellent Very Good Good Fair Poor N/A 9. How would you rate your experience with the front office staff (Check-Out Desk)? Excellent Very Good Good Fair Poor N/A 10. How would you rate your experience with the nurse/medical staff? Excellent Very Good Good Fair Poor N/A 11. How would you rate your experience with the doctor? Excellent Very Good Good Fair Poor N/A 12. How would you rate our respect for your time/informing you of delays? Excellent Very Good Good Fair Poor N/A 13. How would you rate the appearance of our office? Excellent Very Good Good Fair Poor N/A 14. Overall, how would you rate the care and services provided from this office? Excellent Very Good Good Fair Poor N/A 15. If you could go anywhere for treatment, how likely are you to return to us? Excellent Very Good Good Fair Poor N/A Optional Information First Name Last Name Address City State Zip Phone Email Comments reCAPTCHA Submit
