Dear Patient:  As part of our ongoing efforts to provide the highest quality service to our patients we are very interested in receiving your feedback about the care you received from our office.  Please take a few minutes to complete this survey and return it to us.  Your response is very important to us.  Your answers will be kept confidential and all results will be aggregated and utilized to improve patient care.  Thank you in advance for your help.

* 1. Ease of making your appointment by telephone

* 2. Ability to get a appointment as quickly as you wanted it

* 3. Ability to be seen on the day and time that works best for you

* 4. The time that you spent in the waiting room and exam room before seeing your doctor

* 5. The friendliness of the front desk staff

* 6. The caring and concern of the nurses/medical assistants

* 7. The speed with which your telephone calls are answered

* 8. Your ability to get help or advice during office hours by telephone

* 9. The way your doctor listened to your concerns and showed understanding of your health condition

* 10. Your doctor’s explanation of things in a way you could understand

* 11. Ease of understanding instructions regarding your medication and follow-up care

* 12. The availability of your health information, such as test results

* 13. Your doctor’s communication with other providers involved in your care

* 14. Your doctor’s efforts to involve you in planning your own care

* 15. Your doctor’s use of a patient centered approach to your care

* 16. The quality and ease of use of the self-management tools given to you by the practice

* 17. How satisfied are you with our practice overall

* 18. How likely are you to recommend our practice to your friends and family

* 19. Please let us know the reasons you would or would not recommend our practice to others.

* 20. Please let us know if there is anything we can do to improve our services to you.

* 21. Gender:

* 22. Primary language

* 23. Do you have health insurance?

* 24. Insurance Type:

* 25. Date of Service:

* 26. Provider Seen:

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