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Patient Satisfaction Survey Updated

1. Thank you for choosing Boulder Neurosurgical & Spine Associates

The quality of your care is of great importance to BNA. To help us continually improve our services, please take a moment to provide us with your feedback.

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* 1. How would you rate your overall service experience with our practice?

Excellent

Good

Fair

Poor

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* 2. Please rate the following (scale of 1 to 5, with 5 being the best):

	5	4	3	2	1	N/A
Phone manners of general office staff	Phone manners of general office staff 5	Phone manners of general office staff 4	Phone manners of general office staff 3	Phone manners of general office staff 2	Phone manners of general office staff 1	Phone manners of general office staff N/A
Phone manners of our surgeons, PAs and nurses	Phone manners of our surgeons, PAs and nurses 5	Phone manners of our surgeons, PAs and nurses 4	Phone manners of our surgeons, PAs and nurses 3	Phone manners of our surgeons, PAs and nurses 2	Phone manners of our surgeons, PAs and nurses 1	Phone manners of our surgeons, PAs and nurses N/A
Ability to schedule a visit within your desired time frame	Ability to schedule a visit within your desired time frame 5	Ability to schedule a visit within your desired time frame 4	Ability to schedule a visit within your desired time frame 3	Ability to schedule a visit within your desired time frame 2	Ability to schedule a visit within your desired time frame 1	Ability to schedule a visit within your desired time frame N/A
Convenience of your appointment time	Convenience of your appointment time 5	Convenience of your appointment time 4	Convenience of your appointment time 3	Convenience of your appointment time 2	Convenience of your appointment time 1	Convenience of your appointment time N/A
Greeting upon arrival	Greeting upon arrival 5	Greeting upon arrival 4	Greeting upon arrival 3	Greeting upon arrival 2	Greeting upon arrival 1	Greeting upon arrival N/A
Appropriate wait time at office visit	Appropriate wait time at office visit 5	Appropriate wait time at office visit 4	Appropriate wait time at office visit 3	Appropriate wait time at office visit 2	Appropriate wait time at office visit 1	Appropriate wait time at office visit N/A
Courtesy and attentiveness of doctor	Courtesy and attentiveness of doctor 5	Courtesy and attentiveness of doctor 4	Courtesy and attentiveness of doctor 3	Courtesy and attentiveness of doctor 2	Courtesy and attentiveness of doctor 1	Courtesy and attentiveness of doctor N/A
Courtesy and attentiveness of PA	Courtesy and attentiveness of PA 5	Courtesy and attentiveness of PA 4	Courtesy and attentiveness of PA 3	Courtesy and attentiveness of PA 2	Courtesy and attentiveness of PA 1	Courtesy and attentiveness of PA N/A
Courtesy and attentiveness of other staff	Courtesy and attentiveness of other staff 5	Courtesy and attentiveness of other staff 4	Courtesy and attentiveness of other staff 3	Courtesy and attentiveness of other staff 2	Courtesy and attentiveness of other staff 1	Courtesy and attentiveness of other staff N/A
Explanations provided/questions answered	Explanations provided/questions answered 5	Explanations provided/questions answered 4	Explanations provided/questions answered 3	Explanations provided/questions answered 2	Explanations provided/questions answered 1	Explanations provided/questions answered N/A

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* 3. Did the doctor spend enough time with you?

Yes

No

N/A

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* 4. Did the PA spend enough time with you?

Yes

No

N/A

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* 5. Do you feel positive enough about our practice to refer family and friends?

Yes

No

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* 6. How did you hear about BNA. Check all that apply.

Internet Search

Newspaper/TV/Advertisement

Lecture/Event

Friend

Physician Referral

Other (please specify)

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* 7. Who referred you to our practice?

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* 8. Who did you see today?

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* 9. Please comment/provide suggestions regarding anything we can improve to enhance your experience with BNA.

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* 10. Did any staff members go out of their way to make your visit more pleasant or comfortable? If so, will you provide us with their name(s) so that we may acknowledge them?

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* 11. Your name (optional):

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* 12. Please provide a written testimonial and complete the following section indicating your approval to publish this testimonial on our Website. We are also happy to publish your related photo. Please send your photo to kathyb@bnasurg.com.

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* 13. I approve for BNA to post my testimonial on the Website bnasurg.com with (check all that apply):

My full name

Only my initials

My picture - attached

Please do not post my testimonial

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* 14. Input your name and the date below as an electronic signature indicating approval to post your testimonial.

Name

Date