Patient Satisfaction Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential. Thank you for your time

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1. Office:

Office: Bridgeport

Norwalk

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2. Do you currently receive allergy shots?

Do you currently receive allergy shots? Yes

3. OFFICE:

	Poor	Fair	Good	Very Good	Excellent	N/A
Available hours	*OFFICE: Available hours Poor	Available hours Fair	Available hours Good	Available hours Very Good	Available hours Excellent	Available hours N/A
Your waiting time	Your waiting time Poor	Your waiting time Fair	Your waiting time Good	Your waiting time Very Good	Your waiting time Excellent	Your waiting time N/A
Your privacy	Your privacy Poor	Your privacy Fair	Your privacy Good	Your privacy Very Good	Your privacy Excellent	Your privacy N/A
Comfort and cleanliness of waiting room	Comfort and cleanliness of waiting room Poor	Comfort and cleanliness of waiting room Fair	Comfort and cleanliness of waiting room Good	Comfort and cleanliness of waiting room Very Good	Comfort and cleanliness of waiting room Excellent	Comfort and cleanliness of waiting room N/A
Ability to contact us after hours	Ability to contact us after hours Poor	Ability to contact us after hours Fair	Ability to contact us after hours Good	Ability to contact us after hours Very Good	Ability to contact us after hours Excellent	Ability to contact us after hours N/A
Likelihood of referring your friends and family to us	Likelihood of referring your friends and family to us Poor	Likelihood of referring your friends and family to us Fair	Likelihood of referring your friends and family to us Good	Likelihood of referring your friends and family to us Very Good	Likelihood of referring your friends and family to us Excellent	Likelihood of referring your friends and family to us N/A

4. RECEPTION:

	Poor	Fair	Good	Very Good	Excellent	N/A
Phone étiquette	*RECEPTION: Phone étiquette Poor	Phone étiquette Fair	Phone étiquette Good	Phone étiquette Very Good	Phone étiquette Excellent	Phone étiquette N/A
Ease of making appointments	Ease of making appointments Poor	Ease of making appointments Fair	Ease of making appointments Good	Ease of making appointments Very Good	Ease of making appointments Excellent	Ease of making appointments N/A
Receptionist: friendliness	Receptionist: friendliness Poor	Receptionist: friendliness Fair	Receptionist: friendliness Good	Receptionist: friendliness Very Good	Receptionist: friendliness Excellent	Receptionist: friendliness N/A
Receptionist: courtesy	Receptionist: courtesy Poor	Receptionist: courtesy Fair	Receptionist: courtesy Good	Receptionist: courtesy Very Good	Receptionist: courtesy Excellent	Receptionist: courtesy N/A
Receptionist: professionalism	Receptionist: professionalism Poor	Receptionist: professionalism Fair	Receptionist: professionalism Good	Receptionist: professionalism Very Good	Receptionist: professionalism Excellent	Receptionist: professionalism N/A
The efficiency of the check-in process	The efficiency of the check-in process Poor	The efficiency of the check-in process Fair	The efficiency of the check-in process Good	The efficiency of the check-in process Very Good	The efficiency of the check-in process Excellent	The efficiency of the check-in process N/A
The efficiency of the check-out process	The efficiency of the check-out process Poor	The efficiency of the check-out process Fair	The efficiency of the check-out process Good	The efficiency of the check-out process Very Good	The efficiency of the check-out process Excellent	The efficiency of the check-out process N/A

5. NURSES:

	Poor	Fair	Good	Very Good	Excellent	N/A
Friendly and helpful	*NURSES: Friendly and helpful Poor	Friendly and helpful Fair	Friendly and helpful Good	Friendly and helpful Very Good	Friendly and helpful Excellent	Friendly and helpful N/A
The level of caring and concern	The level of caring and concern Poor	The level of caring and concern Fair	The level of caring and concern Good	The level of caring and concern Very Good	The level of caring and concern Excellent	The level of caring and concern N/A
Ability to obtain prescription refills	Ability to obtain prescription refills Poor	Ability to obtain prescription refills Fair	Ability to obtain prescription refills Good	Ability to obtain prescription refills Very Good	Ability to obtain prescription refills Excellent	Ability to obtain prescription refills N/A
Ability to answer you questions	Ability to answer you questions Poor	Ability to answer you questions Fair	Ability to answer you questions Good	Ability to answer you questions Very Good	Ability to answer you questions Excellent	Ability to answer you questions N/A

6. DOCTORS:

	Poor	Fair	Good	Very Good	Excellent	N/A
Friendly and helpful	*DOCTORS: Friendly and helpful Poor	Friendly and helpful Fair	Friendly and helpful Good	Friendly and helpful Very Good	Friendly and helpful Excellent	Friendly and helpful N/A
The level of caring and concern	The level of caring and concern Poor	The level of caring and concern Fair	The level of caring and concern Good	The level of caring and concern Very Good	The level of caring and concern Excellent	The level of caring and concern N/A
The level of trust	The level of trust Poor	The level of trust Fair	The level of trust Good	The level of trust Very Good	The level of trust Excellent	The level of trust N/A
Explanation of your diagnosis and treatment	Explanation of your diagnosis and treatment Poor	Explanation of your diagnosis and treatment Fair	Explanation of your diagnosis and treatment Good	Explanation of your diagnosis and treatment Very Good	Explanation of your diagnosis and treatment Excellent	Explanation of your diagnosis and treatment N/A
Ability to answer you questions	Ability to answer you questions Poor	Ability to answer you questions Fair	Ability to answer you questions Good	Ability to answer you questions Very Good	Ability to answer you questions Excellent	Ability to answer you questions N/A
Effectiveness of your treatment	Effectiveness of your treatment Poor	Effectiveness of your treatment Fair	Effectiveness of your treatment Good	Effectiveness of your treatment Very Good	Effectiveness of your treatment Excellent	Effectiveness of your treatment N/A
Health information materials	Health information materials Poor	Health information materials Fair	Health information materials Good	Health information materials Very Good	Health information materials Excellent	Health information materials N/A

7. BILLING:

	Poor	Fair	Good	Very Good	Excellent	N/A
What you pay	*BILLING: What you pay Poor	What you pay Fair	What you pay Good	What you pay Very Good	What you pay Excellent	What you pay N/A
Explanation of charges	Explanation of charges Poor	Explanation of charges Fair	Explanation of charges Good	Explanation of charges Very Good	Explanation of charges Excellent	Explanation of charges N/A
Collection of payment	Collection of payment Poor	Collection of payment Fair	Collection of payment Good	Collection of payment Very Good	Collection of payment Excellent	Collection of payment N/A

8. Please add any additional comments. Let us know what you like best (and least) about our office. We appreciate all suggestions for improvement.

Please add any additional comments. Let us know what you like best (and least) about our office. We appreciate all suggestions for improvement.

9. OPTIONAL:

OPTIONAL: Name:
Email:

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