Patient Survey Form

Please complete the following Patient Satisfaction Survey form and click "submit" to send your feedback to the practice. Your satisfaction and feedback are very important to us as we will use this information to improve our services to you.

Patient Satisfaction Survey Form

Provider/Physician Seen
Patient Name (Optional)
Patient Email Address (Optional)
Date Visited

Questions
	Rate your satisfaction with the following:
1.	Please rate your satisfaction with the promptness with which your calls were answered.
2.	Please rate your satisfaction with the courtesy of the staff over the telephone.
3.	Please rate your satisfaction with the ease of making appointments for checkups.
4.	Please rate your satisfaction with the ease with which you were able to make appointments for problems.
5.	Please rate your satisfaction with the amount of time your physician spent with you.
6.	Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.
7.	Please rate your satisfaction with the general appearance of the office.
8.	Please rate your satisfaction with the courtesy of the medical assistants during your visit.
9.	Please rate your satisfaction with the overall quality of your care.
10.	Please rate your satisfaction with the availability of a physician after regular office hours.
11.	Please rate your satisfaction with the personal concern shown to you by your physician.
12.	Please rate your satisfaction with explanations of tests or procedures performed.
13.	Please rate your satisfaction with the instructions for taking medications.
14.	Please rate your satisfaction with your opportunity to ask questions.
15.	Please rate your satisfaction with the answers to your questions.
16.	Please rate your satisfaction with the explanation of payment.
17.	Please rate your satisfaction with the results of your care.
18.	Additional comments are welcomed.

Questions

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