* 1. What is your age?

* 2. What is your gender?

* 3. How did you hear about our office?

* 4. Date of Office Visit:

Date
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* 5. Who did you see during your office visit?

* 6. If you called our office to make an appointment, please rate your experience...

  Excellent Very Good Good Fair Poor N/A
Courtesy and professionalism of staff
If a message was left, received a return call within 24-48 business hours
Ease of scheduling an appointment convenient to your schedule
Length of time between scheduling an appointment and the appointment date

* 7. When you arrived for your appointment...

  Excellent Very Good Good Fair Poor N/A
Courtesy and professionalism of receptionist(s)
Billing and insurance questions were addressed
Length of wait in reception area
Appearance and comfort of reception area

* 8. When you were in the exam room...

  Excellent Very Good Good Fair Poor N/A
Length of wait in the exam room
Courtesy and professionalism of nursing staff
Courtesy and professionalism of X-ray staff
If cast was applied, education on cast care was explained clearly
The explanation of your options, cost, and use of Durable Medical Equipment (such as crutches, slings or braces)

* 9. If you were scheduled for surgery, diagnostic test or special procedure (MRI, CT, injection series)...

  Excellent Very Good Good Fair Poor N/A
Courtesy and professionalism of scheduling team member(s)
If a message was left for scheduler, received a call back within 48 business hours
Timeliness of scheduling test or special procedure (within 7 business days)
Timeliness of scheduling Total Joint surgery (dependent on pre-operative screening)
Timeliness of scheduling surgery - excluding Total Joints (notified of surgery date within 3 business days)

* 10. Please rate your experience with the Physician, PA, or NP:

  Excellent Very Good Good Fair Poor N/A
Knowledgable and Professional
Listened to me; showed concern and respect
Explained things in a way I could understand
Spent adequate time with me and answered all my questions
Provided written/verbal education on my condition

* 11. Would you refer a family member or friend to our office?

* 12. What did you like best about your visit?

* 13. What did you like least about your visit? How can we improve?

* 14. May we contact you for permission to use your responses as a patient testimonial?

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