Pomfret Street Family Medical Associates
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1.
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1
. How would you rate your ease of getting an appointment?
How would you rate your ease of getting an appointment?
5. Great
4. Good
3. OK
4. Fair
1. Poor
Comment:
*
2
. How would you rate your ease in reaching the office by telephone?
How would you rate your ease in reaching the office by telephone?
5. Great
4. Good
3. OK
4. Fair
1. Poor
Comment:
*
3
. Did your experience with wait time in the office meet your expectations? (i.e. Were you taken into an exam room on time? or Did you have to wait once your were in the exam room?)
Did your experience with wait time in the office meet your expectations? (i.e. Were you taken into an exam room on time? or Did you have to wait once your were in the exam room?)
5. Great
4. Good
3. OK
4. Fair
1. Poor
Comment:
*
4
. How would you rate the office staff? (front desk, medical assistant or nurses)
How would you rate the office staff? (front desk, medical assistant or nurses)
5. Great
4. Good
3. OK
2. Fair
1. Poor
Comment:
*
5
. Did you feel that the office staff answered your questions?
Did you feel that the office staff answered your questions?
5. Great
4. Good
3. OK
2. Fair
1. Poor
Comment:
*
6
. How would you rate your provider? (doctor, nurse practitioner or physician assistant)
How would you rate your provider? (doctor, nurse practitioner or physician assistant)
5. Great
4. Good
3. OK
2. Fair
1. Poor
Name of Provider
*
7
. Did the provider spend enough time with you? (doctor, nurse practitioner or physician assistant)
Did the provider spend enough time with you? (doctor, nurse practitioner or physician assistant)
5. Great
4. Good
3. OK
2. Fair
1. Poor
Comment:
*
8
. How would you rate the facility? (cleanliness of the building, easy to get to the office, comfort and safety while waiting)
How would you rate the facility? (cleanliness of the building, easy to get to the office, comfort and safety while waiting)
5. Great
4. Good
3. OK
2. Fair
1. Poor
Comment:
*
9
. How would you rate this office in keeping your personal information protected?
How would you rate this office in keeping your personal information protected?
5. Great
4. Good
3. OK
2. Fair
1. Poor
Comment:
*
10
. Likelihood of referring your friends or relatives to this practice.
Likelihood of referring your friends or relatives to this practice.
5. Great
4. Good
3. OK
2. Fair
1. Poor
Comment:
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