Form

We appreciate your honesty and plan to evaluate each survey so as to improve the quality of care we provide to our patients. Thank you for completing this survey
What doctor are you seeing today?
Today's Date
Are you a new patient today?

Yes No
Have you ever referred someone to us?

Yes No
Availability
Ease of scheduling your appointment:
Ease of usinge our telephone system:
Courtesy of person who scheduled your appointment:
Helpfulness of staff on telephone:
Office's timeliness in returning your calls:
While You Were At Our Office
Ease of registration process:
Time spent waiting to be registered:
Friendliness of front desk staff:
Comfort of waiting area:
Time spent waiting before going to exam room:
Comfort of exam room:
Courtesy of nurse and/or medical assistant:
Sensitivity of nurse/medical assistant towards your visit:
Time spent waiting in exam room for provider:
Your Physician
Friendliness/courtesy of your healthcare provider:
Explanations about your visit, or health problem:
Concern provider showed for your questions or worries:
Did the provider include you in decisions about your treatment:
Information provider gave you about your medications:
Instruction provider gave you about follow-up:
Provider spoke to you using language you understood:
Amount of time provider spent with you:
Your confidence in this provider:
Probability you would recommend this provider:
Overall Rating
Overall rating of care you received during your visit:
Overall cleanliness of office:
Our awareness and understanding of your needs:
Availability/accessibility of our office hours:
Our concern for your privacy:
Probability you would recommend our office:
Are there any other services you would like to see us provide?
Was there any particular staff member helpful?
Your Contact Information (optional)
Your Name:
Your Email:
Your Phone:
Should be Empty:

Availability

While You Were At Our Office

Your Physician

Overall Rating

Your Contact Information (optional)