* 1. Please enter:

Date of visit

* 4. Please indicate your level of satisfaction with our facility in the following areas, or mark N/A if you have no basis to judge us in a particular area.

How satisfied were you with:

  NOT Satisfied Somewhat Satisfied Satisfied Very Satisfied N/A
the courtesy and helpfulness of our secretarial staff?
the ability to get a timely appointment?
parking availability?
the orderliness and cleanliness of our reception area?
the courtesy and knowledge of our clinical staff?
the appearance and professionalism of our staff?
the overall quality of our staff?
the time you had to wait after you arrived?
the courtesy of the doctor?
the doctor’s patience and interest in your problem?
the time our staff and physicians spent with you?
the explanation and treatment you received from your doctor?
if you requested an explanation of billing, how satisfied were you with the explanation you were given?
Overall, how satisfied are you with the general quality of medical care you received?

* 5. Would you recommend us to others?

* 6. Other Comments:

* 7. Your Name (Optional)