Patient Survey

Date & time of appointment:

Reception

Ambiance of our office
excellent good average poor

Courtesy of our reception staff
excellent good average poor

Knowledge of the reception staff
excellent good average poor

Ease of accessing our office by phone
excellent good average poor

Ease of the registration process
excellent good average poor

Waiting time in reception area
MINUTES

Medical Staff
(nurses, technologists, nutritionist, etc.)

Courtesy of the medical staff you met with
excellent good average poor

Staff’s concern for your comfort
excellent good average poor

Knowledge of medical staff you met with
excellent good average poor

Ease of accessing medical staff with questions
excellent good average poor

Staff’s concern for your questions or worries
excellent good average poor

Surgery Scheduling

Courtesy of the surgery scheduler
excellent good average poor

Knowledge of the surgery scheduler
excellent good average poor

Ease of accessing a surgery scheduler with questions
excellent good average poor

Physicians

General waiting time for the physician
0-15 Minutes 15-30 Minutes Over 30 Minutes

General impression of your physician
excellent good average poor

Ease of accessing your physician with questions
excellent good average poor

Personal Issues

Concern for your privacy
excellent good average poor

Our sensitivity to your needs
excellent good average poor

In general would you recommend our practice to your friends and family?
yes uncertain no

Any suggestions to improve?

General Comments:

Name (optional):

Would you like us to contact you regarding this survey?
yes no

If YES, please supply your Name:

Phone: