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Patient Satisfaction Survey
1
Is this your first time in our facility?
Yes
No
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2
How frequently do you visit our facility?
Weekly or more
Monthly
Quarterly
Less than quarterly
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3
Do you have an insurance plan?
Yes
No
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4
How satisfied are you with the booking process?
1
2
3
4
5
6
7
8
9
10
Not Satisfied
Very Satisfied
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5
How satisfied are you with check in and welcoming process?
1
2
3
4
5
6
7
8
9
10
Not Satisfied
Very Satisfied
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6
Has the doctor passed the appointment schedule?
Yes
No
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7
How long did you need to wait for the appointment? (past the appointment time)
Less than 30 min.
30 min. - 45 min.
45 min. - 60 min.
More than 60 min.
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8
Professionalism of staff
1
2
3
4
5
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9
Hygiene in the facility
1
2
3
4
5
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10
Kindness of medical personnel
1
2
3
4
5
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11
Care provided by the doctor
1
2
3
4
5
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12
Co-ordination between departments
1
2
3
4
5
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13
By considering overall experience with our facility, how likely would you recommend to your friends/family?
1
2
3
4
5
6
7
8
9
10
Not Likely
Very Likely
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14
Please share any comments/suggestions
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