MKTG 2015 Patient Satisfaction Survey

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* 1. GENERAL INFORMATION:

Today's Date:

Date

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* 2. Appointment Time:

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* 3. What time did you see our physician?

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

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* 5. Which physician are you seeing TODAY:

Dr. Ashe

Dr. Barber

Dr. Burkett

Dr. Cockrell

Dr. Crotwell

Dr. Donahoe

Dr. Fontana

Dr. Granberry

Dr. Hall

Dr. Handwerger

Dr. Hudgens

Dr. Lane

Dr. McAndrew

Dr. Patton

Dr. Revels

Dr. Roca

Dr. Setzler

Dr. Shell

Dr. White-Spunner

Dr. Zarzour

Physical Therapy

Occupational Therapy

MRI

Comment:

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* 6. How did you hear about us?

Family/Friend

Another Physician

Attorney

Emergency Room

Yellow Pages/Phone Book

Community Event

Work Comp

Billboard

Radio

Television

Internet/Our Website

Other

If other, please specify:

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* 7. Did you find our office location convenient?

YES

Comment:

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

YES

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* 9. Did we have adequate parking available today?

YES

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

YES

Comment:

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

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* 12. GENERAL OFFICE:

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

Comment:

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

Comment:

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* 14. GENERAL OFFICE:

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

Comment:

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* 15. GENERAL OFFICE:

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

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* 16. GENERAL OFFICE:

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

Comment:

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

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

YES

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* 19. GENERAL OFFICE:

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

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* 20. GENERAL OFFICE:

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

Comment:

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

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* 22. GENERAL OFFICE:

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

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

YES

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* 24. BUSINESS OFFICE:

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

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

YES

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* 26. THERAPY DEPT:

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

Comment:

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

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* 28. Please explain any of the above responses:

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

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* 30. OVERALL

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

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

YES

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

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

YES

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* 34. Name:

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* 35. Address:

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* 36. City, State

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* 37. Zip:

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* 38. Phone Number:

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* 39. Email address:

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* 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?

YES