Survey

We would love to hear your comments!

Patient service is important to us and we'd like to know how you feel about our medical services, communication systems, and our providers and staff members. Your honest comments will help us continue to evaluate our operations to ensure that we are truly responsive to your needs. Thank you for choosing our practice and taking time to tell us how you feel!

YOUR APPOINTMENT
Ease of making appointments by phone	Excellent	Good	Poor	N/A
How satisfied were you with the availability of getting an appointment	Excellent	Good	Poor	N/A
Please rate the efficiency of our check in and check out process	Excellent	Good	Poor	N/A
Keeping you informed if your appointment time was delayed	Excellent	Good	Poor	N/A
How would you rate your waiting time in the exam room	Excellent	Good	Poor	N/A
Please rate ease of getting referrals and other recommended testing	Excellent	Good	Poor	N/A
Comments:
OUR STAFF
Courtesy and helpfulness of the person who took your phone call	Excellent	Good	Poor	N/A
Friendliness and helpfulness of our staff with the check in and check out process	Excellent	Good	Poor	N/A
How would you rate the medical assistant who escorted you to the exam room? Did you find her to be professional and concerned for your care	Excellent	Good	Poor	N/A
When calling to speak to one of our triage nurses, how would rate their knowledge and compassion for your medical concern	Excellent	Good	Poor	N/A
How would you rate the professionalism and friendliness of our staff in the lab and ultrasound	Excellent	Good	Poor	N/A
When scheduling a surgical procedure, how would you rate the helpfulness and professionalism of the surgical scheduling staff	Excellent	Good	Poor	N/A
Comments:

YOUR VISIT WITH THE PROVIDER
Name of the provider you saw at the time of your visit:
Willingness to listen carefully to you	Excellent	Good	Poor
Taking time to answer your questions and explained things in a way you could understand	Excellent	Good	Poor
How professional and compassionate did you find the provider to be	Excellent	Good	Poor
Instructions regarding medication and/or follow up care	Excellent	Good	Poor
How would rate the thoroughness of the exam	Excellent	Good	Poor
Comments:

OUR COMMUNICATION WITH YOU
How satisfied are you with the response time from our triage nurses	Excellent	Good	Poor	N/A
Please rate your satisfaction with return calls from our Providers	Excellent	Good	Poor	N/A
Your test results reported in a reasonable amount of time	Excellent	Good	Poor	N/A
Explanation of your procedure and efficiency in our scheduling process (if applicable)	Excellent	Good	Poor	N/A
Your ability to contact us after hours	Excellent	Good	Poor	N/A
How satisfied were you with our health information materials	Excellent	Good	Poor	N/A
Comments:
OUR FACILITY
Please rate your overall impression of our facility; waiting areas, exam rooms	Excellent	Good	Poor	N/A
ADDITIONAL COMMENTS:
Please provide any other positive or negative feedback regarding our practice. If there is a particular staff member or provider who you feel provided exceptional patient service we would love to know. Thank you again for your time in completing this survey.

SOME INFORMATION ABOUT YOU:
Your Age (optional):	Under 18 18-30 31-40 41-50 51-64 65+	Are You:	A new patient A returning patient
Security Code	Enter Security Code Above
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