Patient Satisfaction Survey

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* 1. Please indicate the provider you would like to survey:

Dr. Chris Adigun

Leighanne McGill, PA-C

Allyson Adamo, RN

Other (please specify)

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* 2. What was the general purpose of your visit?

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* 3. What made you decide to choose our practice for your visit?

Friend/family referral

Physician referral

Website

Reputation/Experience of Doctor

Information provided to me

Magazine ad

Cost

Facility/Office location

Social Media

Other (please specify)

Question Title

* 4. When you called for your appointment, how would you rate the response from the person who answered the telephone?

Excellent

Good

Average

Fair

Poor

Excellent

Good

Average

Fair

Poor

Other (please specify)

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* 5. When you arrived at the office, how would you rate the Front Office Representative in the following areas?

	Excellent	Good	Average	Fair	Poor
Friendly and courteous?	Friendly and courteous? Excellent	Friendly and courteous? Good	Friendly and courteous? Average	Friendly and courteous? Fair	Friendly and courteous? Poor
Helpful?	Helpful? Excellent	Helpful? Good	Helpful? Average	Helpful? Fair	Helpful? Poor

Other (please specify)

Question Title

* 6. During your visit, how would you rate our clinic staff in the following areas?

	Excellent	Good	Average	Fair	Poor
Friendly and courteous?	Friendly and courteous? Excellent	Friendly and courteous? Good	Friendly and courteous? Average	Friendly and courteous? Fair	Friendly and courteous? Poor
Helpful/Knowledgeable?	Helpful/Knowledgeable? Excellent	Helpful/Knowledgeable? Good	Helpful/Knowledgeable? Average	Helpful/Knowledgeable? Fair	Helpful/Knowledgeable? Poor
Competent and professional?	Competent and professional? Excellent	Competent and professional? Good	Competent and professional? Average	Competent and professional? Fair	Competent and professional? Poor
Sympathetic and caring?	Sympathetic and caring? Excellent	Sympathetic and caring? Good	Sympathetic and caring? Average	Sympathetic and caring? Fair	Sympathetic and caring? Poor

Other (please specify)

Question Title

* 7. During your visit, how would you rate the physician or physician assistant in the following areas?

	Excellent	Good	Average	Fair	Poor
Friendly and courteous?	Friendly and courteous? Excellent	Friendly and courteous? Good	Friendly and courteous? Average	Friendly and courteous? Fair	Friendly and courteous? Poor
Competent and professional?	Competent and professional? Excellent	Competent and professional? Good	Competent and professional? Average	Competent and professional? Fair	Competent and professional? Poor
Sympathetic and caring?	Sympathetic and caring? Excellent	Sympathetic and caring? Good	Sympathetic and caring? Average	Sympathetic and caring? Fair	Sympathetic and caring? Poor

Other (please specify)

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* 8. Do you feel you were given adequate information about:

	Yes	No
The overall procedure	The overall procedure Yes	The overall procedure No
The doctor's experience	The doctor's experience Yes	The doctor's experience No
Total fees	Total fees Yes	Total fees No
Possible side effects	Possible side effects Yes	Possible side effects No
Procedure results	Procedure results Yes	Procedure results No

Other (please specify)

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* 9. Please comment on any staff interaction and/or ideas how to improve our service. We learn the most directly from your comments, so please feel free to share without worries of offending us; our goal is to provide the highest patient experience imaginable!

Question Title

* 1. Please indicate the provider you would like to survey:

Question Title

* 2. What was the general purpose of your visit?

Question Title

* 3. What made you decide to choose our practice for your visit?

Question Title

* 4. When you called for your appointment, how would you rate the response from the person who answered the telephone?

Question Title

* 5. When you arrived at the office, how would you rate the Front Office Representative in the following areas?

Question Title

* 6. During your visit, how would you rate our clinic staff in the following areas?

Question Title

* 7. During your visit, how would you rate the physician or physician assistant in the following areas?

Question Title

* 8. Do you feel you were given adequate information about:

Question Title

* 9. Please comment on any staff interaction and/or ideas how to improve our service. We learn the most directly from your comments, so please feel free to share without worries of offending us; our goal is to provide the highest patient experience imaginable!

Question Title

* 10. Would you like to give a patient testimonial using your first name only?