Patient Survey
Name
First Name
Last Name
Physician
Dr. Doe
Dr. Smith
Dr. James
How would you rate...
Rows
Very Poor
Poor
Average
Good
Very Good
Our waiting room (is it clean and comfortable)?
1
2
3
4
5
Our administrative staff (did they help you promptly and answer your questions)?
6
7
8
9
10
Your nurse (were they pleasant and professional)?
11
12
13
14
15
Your physician (did they address your issue and answer your questions clearly)?
16
17
18
19
20
Your wait time (were you seen promptly)?
21
22
23
24
25
Your overall experience?
26
27
28
29
30
Do you have any additional feedback?
Submit
Should be Empty: