Clinic Patient Satisfaction Survey
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What is today's date?

What time was your appointment?

What physician, nurse practitioner or clinic specialist are you seeing?

	Very Satisfied	Satisfied	Dissatisfied	Does Not Apply
Ease of making an appointment	*APPOINTMENT - How satisfied were you with the: Ease of making an appointment Very Satisfied	Ease of making an appointment Satisfied	Ease of making an appointment Dissatisfied	Ease of making an appointment Does Not Apply
Appointment Availability	Appointment Availability Very Satisfied	Appointment Availability Satisfied	Appointment Availability Dissatisfied	Appointment Availability Does Not Apply
Appointment Reminder	Appointment Reminder Very Satisfied	Appointment Reminder Satisfied	Appointment Reminder Dissatisfied	Appointment Reminder Does Not Apply
Check-In Process	Check-In Process Very Satisfied	Check-In Process Satisfied	Check-In Process Dissatisfied	Check-In Process Does Not Apply
Courtesy of Staff	Courtesy of Staff Very Satisfied	Courtesy of Staff Satisfied	Courtesy of Staff Dissatisfied	Courtesy of Staff Does Not Apply
Wait time in the reception area	Wait time in the reception area Very Satisfied	Wait time in the reception area Satisfied	Wait time in the reception area Dissatisfied	Wait time in the reception area Does Not Apply
Obtaining medical and vital signs	Obtaining medical and vital signs Very Satisfied	Obtaining medical and vital signs Satisfied	Obtaining medical and vital signs Dissatisfied	Obtaining medical and vital signs Does Not Apply

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Clinic Patient Satisfaction SurveyExit this survey