Patient Survey
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Piñon Perinatal Patient Survey

Dear Patient: According to our records, you recently visited the provider named above. Please tell us your opinion about the service you received from this provider. Your responses will be kept strictly confidential. Thanks for your help.

PLEASE RATE THE FOLLOWING:

1. YOUR APPOINTMENT:

	Excellent	Very Good	Good	Fair	Poor	N/A
Appointment available within a reasonable amount of time	*YOUR APPOINTMENT: Appointment available within a reasonable amount of time Excellent	Appointment available within a reasonable amount of time Very Good	Appointment available within a reasonable amount of time Good	Appointment available within a reasonable amount of time Fair	Appointment available within a reasonable amount of time Poor	Appointment available within a reasonable amount of time N/A
The efficiency of the check-in process	The efficiency of the check-in process Excellent	The efficiency of the check-in process Very Good	The efficiency of the check-in process Good	The efficiency of the check-in process Fair	The efficiency of the check-in process Poor	The efficiency of the check-in process N/A
Waiting time in the reception area	Waiting time in the reception area Excellent	Waiting time in the reception area Very Good	Waiting time in the reception area Good	Waiting time in the reception area Fair	Waiting time in the reception area Poor	Waiting time in the reception area N/A
Waiting time in the exam room	Waiting time in the exam room Excellent	Waiting time in the exam room Very Good	Waiting time in the exam room Good	Waiting time in the exam room Fair	Waiting time in the exam room Poor	Waiting time in the exam room N/A
Keeping you informed if your appointment time was delayed	Keeping you informed if your appointment time was delayed Excellent	Keeping you informed if your appointment time was delayed Very Good	Keeping you informed if your appointment time was delayed Good	Keeping you informed if your appointment time was delayed Fair	Keeping you informed if your appointment time was delayed Poor	Keeping you informed if your appointment time was delayed N/A

2. OUR STAFF:

	Excellent	Very Good	Good	Fair	Poor	N/A
Did you receive a phone call reminding you of the appoinment; was the calling person courteous	*OUR STAFF: Did you receive a phone call reminding you of the appoinment; was the calling person courteous Excellent	Did you receive a phone call reminding you of the appoinment; was the calling person courteous Very Good	Did you receive a phone call reminding you of the appoinment; was the calling person courteous Good	Did you receive a phone call reminding you of the appoinment; was the calling person courteous Fair	Did you receive a phone call reminding you of the appoinment; was the calling person courteous Poor	Did you receive a phone call reminding you of the appoinment; was the calling person courteous N/A
The friendliness and courtesy of the receptionist	The friendliness and courtesy of the receptionist Excellent	The friendliness and courtesy of the receptionist Very Good	The friendliness and courtesy of the receptionist Good	The friendliness and courtesy of the receptionist Fair	The friendliness and courtesy of the receptionist Poor	The friendliness and courtesy of the receptionist N/A
The caring concern of our sonographers/counselors/nurse practitioners	The caring concern of our sonographers/counselors/nurse practitioners Excellent	The caring concern of our sonographers/counselors/nurse practitioners Very Good	The caring concern of our sonographers/counselors/nurse practitioners Good	The caring concern of our sonographers/counselors/nurse practitioners Fair	The caring concern of our sonographers/counselors/nurse practitioners Poor	The caring concern of our sonographers/counselors/nurse practitioners N/A
The helpfulness of the people who assisted you with billing or insurance	The helpfulness of the people who assisted you with billing or insurance Excellent	The helpfulness of the people who assisted you with billing or insurance Very Good	The helpfulness of the people who assisted you with billing or insurance Good	The helpfulness of the people who assisted you with billing or insurance Fair	The helpfulness of the people who assisted you with billing or insurance Poor	The helpfulness of the people who assisted you with billing or insurance N/A
The professionalism of our staff	The professionalism of our staff Excellent	The professionalism of our staff Very Good	The professionalism of our staff Good	The professionalism of our staff Fair	The professionalism of our staff Poor	The professionalism of our staff N/A

3. OUR COMMUNICATION WITH YOU:

	Excellent	Very Good	Good	Fair	Poor	N/A
Your phone calls answered promptly	*OUR COMMUNICATION WITH YOU: Your phone calls answered promptly Excellent	Your phone calls answered promptly Very Good	Your phone calls answered promptly Good	Your phone calls answered promptly Fair	Your phone calls answered promptly Poor	Your phone calls answered promptly N/A
Getting advice or help when needed during office hours	Getting advice or help when needed during office hours Excellent	Getting advice or help when needed during office hours Very Good	Getting advice or help when needed during office hours Good	Getting advice or help when needed during office hours Fair	Getting advice or help when needed during office hours Poor	Getting advice or help when needed during office hours N/A
Explanation of your ultrasound findings and procedures (if applicable)	Explanation of your ultrasound findings and procedures (if applicable) Excellent	Explanation of your ultrasound findings and procedures (if applicable) Very Good	Explanation of your ultrasound findings and procedures (if applicable) Good	Explanation of your ultrasound findings and procedures (if applicable) Fair	Explanation of your ultrasound findings and procedures (if applicable) Poor	Explanation of your ultrasound findings and procedures (if applicable) N/A
Effectiveness of our health information materials	Effectiveness of our health information materials Excellent	Effectiveness of our health information materials Very Good	Effectiveness of our health information materials Good	Effectiveness of our health information materials Fair	Effectiveness of our health information materials Poor	Effectiveness of our health information materials N/A
If diabetic, were your phone calls to the diabetic educator answer in a timely manner	If diabetic, were your phone calls to the diabetic educator answer in a timely manner Excellent	If diabetic, were your phone calls to the diabetic educator answer in a timely manner Very Good	If diabetic, were your phone calls to the diabetic educator answer in a timely manner Good	If diabetic, were your phone calls to the diabetic educator answer in a timely manner Fair	If diabetic, were your phone calls to the diabetic educator answer in a timely manner Poor	If diabetic, were your phone calls to the diabetic educator answer in a timely manner N/A

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Piñon Perinatal Patient Survey

1. YOUR APPOINTMENT:

2. OUR STAFF:

3. OUR COMMUNICATION WITH YOU:

Patient Survey
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