GCRS - Tell us how we are doing Survey

1. Providers/Physician Seen

Providers/Physician Seen

2. Patient Name

Patient Name

3. Patient Email Address

Patient Email Address

4. Date Visited

	MM		DD		YYYY
Date:	Date Visited Date: Month	/	Day	/	Year

5. Please rate your satisfaction with the promptness with which your calls were answered.

Please rate your satisfaction with the promptness with which your calls were answered.

6. Please rate your satisfaction with the courtesy of the staff over the telephone.

Please rate your satisfaction with the courtesy of the staff over the telephone.

7. Please rate you satisfaction with the ease of making appointments for checkups.

Please rate you satisfaction with the ease of making appointments for checkups.

8. Please rate your satisfaction with the ease with which you were able to make appointments for problems.

Please rate your satisfaction with the ease with which you were able to make appointments for problems.

9. Please rate your satisfaction with the amount of time your physician spent with you.

Please rate your satisfaction with the amount of time your physician spent with you.

10. Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.

Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.

11. Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.

Please rate your satisfaction with the courtesy of the staff when you arrived for your appointments.

12. Please rate your satisfaction with the general appearance of the office.

Please rate your satisfaction with the general appearance of the office.

13. Please rate your satisfaction with the courtesy of the medical assistants during your visit.

Please rate your satisfaction with the courtesy of the medical assistants during your visit.

14. Please rate your satisfaction with the overall quality of your care.

Please rate your satisfaction with the overall quality of your care.

15. Please rate your satisfaction with the availability of a physician after regular office hours.

Please rate your satisfaction with the availability of a physician after regular office hours.

16. Please rate your satisfaction with the personal concern shown to you by your physician.

Please rate your satisfaction with the personal concern shown to you by your physician.

17. Please rate your satisfaction with explanations of tests or procedures performed.

Please rate your satisfaction with explanations of tests or procedures performed.

18. Please rate your satisfaction with the instructions for taking medications.

Please rate your satisfaction with the instructions for taking medications.

19. Please rate your satisfaction with your opportunity to ask questions.

Please rate your satisfaction with your opportunity to ask questions.

20. Please rate your satisfaction with the answers to your questions.

Please rate your satisfaction with the answers to your questions.

21. Please rate your satisfaction with the explanation of payment.

Please rate your satisfaction with the explanation of payment.

22. Please rate your satisfaction with the results of your care.

Please rate your satisfaction with the results of your care.

23. Additional comments are welcomed.

Additional comments are welcomed.

GCRS - Tell us how we are doingExit this survey

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