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Patient Satisfaction Questionnaire for Office Visits

 

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1. Please enter:

	MM		DD		YYYY
Date of visit	Please enter:   Date of visit   Month	/	Day	/	Year

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2. Questionnaire Completed By:

PatientParentGuardian

Questionnaire Completed By:

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3. Please select the physician your visit was with

Bruce Cassidy, M.D.Robert Daly, M.D.William Holt, M.D.Jacqueline Nguyen, M.D.Elizabeth Serrage, M.D.Samuel Solish, M.D.Jordan Sterrer, M.D.Scott Steidl, M.D.

Please select the physician your visit was with

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4. Please indicate your level of satisfaction with our facility in the following areas, or mark N/A if you have no basis to judge us in a particular area.

How satisfied were you with:

	NOT Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied	N/A
the courtesy and helpfulness of our secretarial staff?	*Please indicate your level of satisfaction with our facility in the following areas, or mark N/A if you have no basis to judge us in a particular area. How satisfied were you with: the courtesy and helpfulness of our secretarial staff? NOT Satisfied	the courtesy and helpfulness of our secretarial staff? Somewhat Satisfied	the courtesy and helpfulness of our secretarial staff? Satisfied	the courtesy and helpfulness of our secretarial staff? Very Satisfied	the courtesy and helpfulness of our secretarial staff? N/A
the ability to get a timely appointment?	the ability to get a timely appointment? NOT Satisfied	the ability to get a timely appointment? Somewhat Satisfied	the ability to get a timely appointment? Satisfied	the ability to get a timely appointment? Very Satisfied	the ability to get a timely appointment? N/A
parking availability?	parking availability? NOT Satisfied	parking availability? Somewhat Satisfied	parking availability? Satisfied	parking availability? Very Satisfied	parking availability? N/A
the orderliness and cleanliness of our reception area?	the orderliness and cleanliness of our reception area? NOT Satisfied	the orderliness and cleanliness of our reception area? Somewhat Satisfied	the orderliness and cleanliness of our reception area? Satisfied	the orderliness and cleanliness of our reception area? Very Satisfied	the orderliness and cleanliness of our reception area? N/A
the courtesy and knowledge of our clinical staff?	the courtesy and knowledge of our clinical staff? NOT Satisfied	the courtesy and knowledge of our clinical staff? Somewhat Satisfied	the courtesy and knowledge of our clinical staff? Satisfied	the courtesy and knowledge of our clinical staff? Very Satisfied	the courtesy and knowledge of our clinical staff? N/A
the appearance and professionalism of our staff?	the appearance and professionalism of our staff? NOT Satisfied	the appearance and professionalism of our staff? Somewhat Satisfied	the appearance and professionalism of our staff? Satisfied	the appearance and professionalism of our staff? Very Satisfied	the appearance and professionalism of our staff? N/A
the overall quality of our staff?	the overall quality of our staff? NOT Satisfied	the overall quality of our staff? Somewhat Satisfied	the overall quality of our staff? Satisfied	the overall quality of our staff? Very Satisfied	the overall quality of our staff? N/A
the time you had to wait after you arrived?	the time you had to wait after you arrived? NOT Satisfied	the time you had to wait after you arrived? Somewhat Satisfied	the time you had to wait after you arrived? Satisfied	the time you had to wait after you arrived? Very Satisfied	the time you had to wait after you arrived? N/A
the courtesy of the doctor?	the courtesy of the doctor? NOT Satisfied	the courtesy of the doctor? Somewhat Satisfied	the courtesy of the doctor? Satisfied	the courtesy of the doctor? Very Satisfied	the courtesy of the doctor? N/A
the doctor’s patience and interest in your problem?	the doctor’s patience and interest in your problem? NOT Satisfied	the doctor’s patience and interest in your problem? Somewhat Satisfied	the doctor’s patience and interest in your problem? Satisfied	the doctor’s patience and interest in your problem? Very Satisfied	the doctor’s patience and interest in your problem? N/A
the time our staff and physicians spent with you?	the time our staff and physicians spent with you? NOT Satisfied	the time our staff and physicians spent with you? Somewhat Satisfied	the time our staff and physicians spent with you? Satisfied	the time our staff and physicians spent with you? Very Satisfied	the time our staff and physicians spent with you? N/A
the explanation and treatment you received from your doctor?	the explanation and treatment you received from your doctor? NOT Satisfied	the explanation and treatment you received from your doctor? Somewhat Satisfied	the explanation and treatment you received from your doctor? Satisfied	the explanation and treatment you received from your doctor? Very Satisfied	the explanation and treatment you received from your doctor? N/A
if you requested an explanation of billing, how satisfied were you with the explanation you were given?	if you requested an explanation of billing, how satisfied were you with the explanation you were given? NOT Satisfied	if you requested an explanation of billing, how satisfied were you with the explanation you were given? Somewhat Satisfied	if you requested an explanation of billing, how satisfied were you with the explanation you were given? Satisfied	if you requested an explanation of billing, how satisfied were you with the explanation you were given? Very Satisfied	if you requested an explanation of billing, how satisfied were you with the explanation you were given? N/A
Overall, how satisfied are you with the general quality of medical care you received?	Overall, how satisfied are you with the general quality of medical care you received? NOT Satisfied	Overall, how satisfied are you with the general quality of medical care you received? Somewhat Satisfied	Overall, how satisfied are you with the general quality of medical care you received? Satisfied	Overall, how satisfied are you with the general quality of medical care you received? Very Satisfied	Overall, how satisfied are you with the general quality of medical care you received? N/A

5. Would you recommend us to others?

Would you recommend us to others?   Yes No

6. Other Comments:

Other Comments:

7. Your Name (Optional)

Your Name (Optional)