Huron Valley Urology Associates Patient Satisfaction Survey

Dear Patient,
Please take a few minutes to let us know how we are doing and how we can serve you better. Our goal is to provide compassionate, dignified care for all patients. We would like to know how you feel about our staff, providers, and service. Your comments will be evaluated to ensure that we are doing the best we can for your medical needs. Thank you for your participation.

1. Most Recent visit

	MM		DD		YYYY
Date of your visit	Most Recent visit Date of your visit Month	/	Day	/	Year

2. Which medical provider did you see?

Which medical provider did you see? Dr. Goh

Dr. Kleer

Dr. McHugh

Dr. Siddiqi

Dr. Solomon

C. Sanocki - NP

M. Wilson - US Tech.

Nurse

Please rate the following:

3. Our Communication with You.

	Excellent	Very Good	Good	Fair/Poor	N/A
Rate the ease of getting ahold of our clinic by phone, including how promptly your calls were answered.	Our Communication with You. Rate the ease of getting ahold of our clinic by phone, including how promptly your calls were answered. Excellent	Rate the ease of getting ahold of our clinic by phone, including how promptly your calls were answered. Very Good	Rate the ease of getting ahold of our clinic by phone, including how promptly your calls were answered. Good	Rate the ease of getting ahold of our clinic by phone, including how promptly your calls were answered. Fair/Poor	Rate the ease of getting ahold of our clinic by phone, including how promptly your calls were answered. N/A
Rate your satisfaction with your scheduled appointment date and time.	Rate your satisfaction with your scheduled appointment date and time. Excellent	Rate your satisfaction with your scheduled appointment date and time. Very Good	Rate your satisfaction with your scheduled appointment date and time. Good	Rate your satisfaction with your scheduled appointment date and time. Fair/Poor	Rate your satisfaction with your scheduled appointment date and time. N/A
Rate your satisfaction with making an appointment and the overall ease of the appointment process.	Rate your satisfaction with making an appointment and the overall ease of the appointment process. Excellent	Rate your satisfaction with making an appointment and the overall ease of the appointment process. Very Good	Rate your satisfaction with making an appointment and the overall ease of the appointment process. Good	Rate your satisfaction with making an appointment and the overall ease of the appointment process. Fair/Poor	Rate your satisfaction with making an appointment and the overall ease of the appointment process. N/A

4. Waiting Time

	Excellent	Very Good	Good	Fair/Poor	N/A
Rate your satisfaction with the amount of time you spent in our office, including the waiting room and the exam room.	Waiting Time Rate your satisfaction with the amount of time you spent in our office, including the waiting room and the exam room. Excellent	Rate your satisfaction with the amount of time you spent in our office, including the waiting room and the exam room. Very Good	Rate your satisfaction with the amount of time you spent in our office, including the waiting room and the exam room. Good	Rate your satisfaction with the amount of time you spent in our office, including the waiting room and the exam room. Fair/Poor	Rate your satisfaction with the amount of time you spent in our office, including the waiting room and the exam room. N/A

5. Our Staff

	Excellent	Very Good	Good	Fair/Poor	N/A
Rate the courtesy, friendliness and consideration of our staff.	Our Staff Rate the courtesy, friendliness and consideration of our staff. Excellent	Rate the courtesy, friendliness and consideration of our staff. Very Good	Rate the courtesy, friendliness and consideration of our staff. Good	Rate the courtesy, friendliness and consideration of our staff. Fair/Poor	Rate the courtesy, friendliness and consideration of our staff. N/A

6. Your visit with your medical provider

	Excellent	Very Good	Good	Fair/Poor	N/A
Rate your satisfaction with your medical provider and the outcome of your treatment.	Your visit with your medical provider Rate your satisfaction with your medical provider and the outcome of your treatment. Excellent	Rate your satisfaction with your medical provider and the outcome of your treatment. Very Good	Rate your satisfaction with your medical provider and the outcome of your treatment. Good	Rate your satisfaction with your medical provider and the outcome of your treatment. Fair/Poor	Rate your satisfaction with your medical provider and the outcome of your treatment. N/A

7. Our Facility

	Excellent	Very Good	Good	Fair/Poor	N/A
Rate your satisfaction with our hours of operation, facilities, cleanliness/safety and directions to our office.	Our Facility Rate your satisfaction with our hours of operation, facilities, cleanliness/safety and directions to our office. Excellent	Rate your satisfaction with our hours of operation, facilities, cleanliness/safety and directions to our office. Very Good	Rate your satisfaction with our hours of operation, facilities, cleanliness/safety and directions to our office. Good	Rate your satisfaction with our hours of operation, facilities, cleanliness/safety and directions to our office. Fair/Poor	Rate your satisfaction with our hours of operation, facilities, cleanliness/safety and directions to our office. N/A

8. Your Overall Satisfaction

	Excellent	Very Good	Good	Fair/Poor	N/A
Rate your overall satisfaction of our practice and the quality of your care.	Your Overall Satisfaction Rate your overall satisfaction of our practice and the quality of your care. Excellent	Rate your overall satisfaction of our practice and the quality of your care. Very Good	Rate your overall satisfaction of our practice and the quality of your care. Good	Rate your overall satisfaction of our practice and the quality of your care. Fair/Poor	Rate your overall satisfaction of our practice and the quality of your care. N/A

9. How likely are you to recommend Huron Valley Urology Associates to a family member, colleague, or friend?

How likely are you to recommend Huron Valley Urology Associates to a family member, colleague, or friend? Extremely Likely

Very Likely

Likely

Not Very Likely

Not At All Likely

10. Additional comments/concerns.

Additional comments/concerns.