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* 1. GENERAL INFORMATION:

Today's Date:
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* 2. Appointment Time:

* 3. What time did you see our physician?

* 4. What time did you checkout (schedule next appt, pay co-pay, etc)?

* 5. Which physician are you seeing TODAY:

* 6. How did you hear about us?

* 7. Did you find our office location convenient?

* 8. Did you find our waiting area to be comfortable today?

* 9. Did we have adequate parking available today?

* 10. Did our parking attendant pick you up at your car and deliver you to the front entrance?

* 11. What is your zip code? (so we can track how many miles you traveled to reach our office)

* 12. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
How were you greeted on your initial phone call?

* 13. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Did you find it easy to schedule an appointment in a timely manner?

* 14. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Was the front desk staff courteous and helpful when you checked in?

* 15. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Please rate your wait time today

* 16. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Was the nursing staff responsive and considerate of your needs?

* 17. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Did the nursing staff return your phone calls in a prompt and professional manner?

* 18. Did you meet with one of our Financial Counselors today?

* 19. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Was our Financial Counselor professional and courteous?

* 20. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Was the x-ray staff courteous & responsive to your needs?

* 21. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Did your physician carefully explain the diagnosis, treatment & follow-up instructions to you?

* 22. GENERAL OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Did your physician spend adequate time with your during your visit?

* 23. Did you speak to one of our Business Office Representatives over the phone regarding your medical bill?

* 24. BUSINESS OFFICE:

  Excellent Very Good Average Poor Very Poor N/A
Was our Business Office Representative professional and courteous?

* 25. Did you attend Physical or Occupational Therapy today?

* 26. THERAPY DEPT:

  Excellent Very Good Average Poor Very Poor N/A
Was our Therapy staff professional and courteous in handling your needs today?

* 27. THERAPY DEPT:

  Excellent Very Good Average Poor Very Poor N/A
How would you rate your OVERALL quality of care provided by our therapy department?

* 28. Please explain any of the above responses:

* 29. OVERALL

  Excellent Very Good Average Poor Very Poor N/A
Do you believe that you received the highest quality of care from your physician?

* 30. OVERALL

  Excellent Very Good Average Poor Very Poor N/A
How would you rate your overall quality of care provided by AOC?

* 31. Would you recommend AOC to your family or friends?

* 32. Do you have any recommendations on how we might serve you better?

* 33. May we contact you regarding your responses to this survey?

* 34. Name:

* 35. Address:

* 36. City, State

* 37. Zip:

* 38. Phone Number:

* 39. Email address:

* 40. Occasionally, AOC physicians offer free seminars to our patients and our community regarding orthopaedic topics and medical procedures. Would you like to be added to our mailing list so you will receive an invitation to our free seminars?

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