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Patient Satisfaction Survey

We thank you in advance for completing this survey.

Patient Name  
Name of person completing the survey  
Date of visit  
Provider Visited  
Office location of visit  
Was this the Patient's First Visit?  
Patient's Age  
Patient's Sex  
How many minutes after your scheduled appointment time were you still in the waiting room?  
How many minutes were you waiting in the exam room before a technician, nurse, or physician came in?  
Email:  

Scheduling and Telephone Experience


   
Very
Poor
Poor Fair Good Very
Good
Ease of Scheduling your appointment:  
Demeanor of the person who scheduled your appointment:  
The ability to answer questions regarding your appointment:  
The ability to answer questions regarding invoices/billing:  
The ability to answer questions regarding your insurance:  
Promptness in returning your phone call (if applicable):  

Waiting Room Experience


   
Very
Poor
Poor Fair Good Very
Good
Speed and ease of the registration process:  
Demeanor of the staff in the registration area:  
Comfort and pleasantness of the waiting area:
 
Length of wait before entering the exam room:  

Exam Room Experience


   
Very
Poor
Poor Fair Good Very
Good
Comfort and pleasantness of the exam room:  
Demeanor of the nurse/assistant:  
Time in the exam room before being seen by the care provider:
 
Demeanor of the care provider:  
Explanations the care provider gave you about your condition:  
Concern the care provider showed for your questions:
 
Ability of the care provider to listen and answer your questions:  
The extent to which care provider included you in decisions regarding treatment:  
Information the care provider gave you about any medications:  
Instructions the care provider gave you about follow-up care:  
Ease in understanding the information given by your care provider:  
Amount of time the care provider spent with you:  
Your confidence in this care provider:  
Likelihood you would recommend this care provider:  

Overall Assessment


   
Very Poor Poor Fair Good Very Good
Convenience of our office hours:  
Our sensitivity to your needs:  
Our concern for your privacy:
 
Overall demeanor of our practice:  
Overall cleanliness of our environment:  
Overall rating of care received during your visit:
 
Likelihood of recommending our practice to others:  

Comments


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