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Patient Procedure Questionnaire
We want to be sure that we offer you the highest level of service and medical care. Help us by completing this brief, confidential survey below.
1
. Patient name (Optional)
Patient name (Optional)
2
. Which provider(s) did you see today?
Which provider(s) did you see today?
Dr. Anant Damle
Dr. Tom Duntemann
Dr. Norman Goldin
Dr. Mark Lawson
Dr. Dan Neumann
3
. Before you arrived, were you given a clear explanation of any instructions that you needed to follow before having your examination?
Before you arrived, were you given a clear explanation of any instructions that you needed to follow before having your examination?
Yes
No
4
. Did you have a long wait before the procedure?
Did you have a long wait before the procedure?
Yes
No
5
. Was the area clean?
Was the area clean?
Yes
No
6
. Was the staff polite?
Was the staff polite?
Yes
No
7
. Was your procedure clearly explained?
Was your procedure clearly explained?
Yes
No
8
. After your procedure, did you receive clear instructions about any directions you needed to follow after going home?
After your procedure, did you receive clear instructions about any directions you needed to follow after going home?
Yes
No
9
. Did you feel you were provided with appropriate privacy?
Did you feel you were provided with appropriate privacy?
Yes
No
10
. Would you return to our office again if you needed medical services?
Would you return to our office again if you needed medical services?
Yes
No
If no, why not?
11
. How would you rate your overall experience with us?
How would you rate your overall experience with us?
1 Worst
2
3
4
5
6
7
8
9
10 Best
12
. Additional comments or questions?
Additional comments or questions?
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