1. Satisfaction Survey

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* 1. Please rank your satisfaction with our services in the following areas:

  Extremely satisfied Satisfied Fair dissatisfied Extremely dissatisfied
Length of time it took to get an appointment
Length of time spent in office waiting to be seen
Cleanliness/comfort of office
Friendliness and helpfulness of front desk staff
Friendliness and helpfulness of nursing staff
Friendliness and helpfulness of practitioner
Explanation of diagnosis
Explanation of prescribed medications and side effects
Practice staff concern for your privacy
Overall satisfaction with the practice

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* 2. Please provide additional information relating to experience with the physician office:

  Yes No
Would you reccomend this practice to family or friends?
Was this your first visit to the office?

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* 3. What date was your appointment?

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* 4. How did you hear about our practice?

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* 5. Which provider did you see at this visit?

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* 6. If you needed tests, did you use CCMH services

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* 7. Did you require additional tests (laboratory, radiology, cardiology, etc)

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* 8. How old are you?

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* 9. Were there any staff members who were especially helpful that you would like to mention?

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* 10. What suggestions do you have for how we can improve our services?

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* 11. If you would like someone to contact you regarding the experience you had at the physician office, please complete the following:

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