Clinician and Group Patient Experience Survey Form
Please share your feedback about your recent experience. Your responses help us improve our services.
How would you rate your overall experience with our clinician or group?
*
1
2
3
4
5
How easy was it to schedule your appointment?
*
Very Difficult
1
2
3
4
Very Easy
5
1 is Very Difficult, 5 is Very Easy
How satisfied were you with the communication from our staff?
*
Very Dissatisfied
1
2
3
4
Very Satisfied
5
1 is Very Dissatisfied, 5 is Very Satisfied
How likely are you to recommend our clinician or group to others?
*
Very likely
Likely
Neutral
Unlikely
Very unlikely
Please indicate your level of agreement with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
The clinician or group listened carefully to me.
1
2
3
4
5
I was treated with respect.
6
7
8
9
10
My questions were answered clearly.
11
12
13
14
15
The environment was comfortable.
16
17
18
19
20
Did you feel involved in decisions about your care?
*
Yes
No
Not applicable
How would you rate the clarity of instructions or information you received?
*
1
2
3
4
5
How long did you wait past your scheduled appointment time?
*
Please Select
Less than 5 minutes
5-15 minutes
16-30 minutes
More than 30 minutes
Not applicable
What was the main reason for your visit?
*
Please Select
Routine check-up
Follow-up
Consultation
Treatment or procedure
Other
Please share any additional comments or suggestions.
Submit Feedback
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