1. Default Section

* 1. With whom did you have your last appointment/surgery with?

* 2. What type of appointment were you seen for?

* 3. Please rate the following items as they relate to making your appointment:

  very poor poor fair good very good
Availability of physician's schedule
Helpfulness of the staff on the telephone
Our timeliness in returning your calls

* 4. Please rate the following items as they relate to your appointment:

  very poor poor fair good very good
Speed of the check-in process
Attitude of the receptionists
Comfort of the waiting room
Length of wait from your appointment time to entering exam room

* 5. Please rate the following items as they relate to your care:

  very poor poor fair good very good
Friendliness of the physician
Explanation of care regarding your condition
Physician's level of attentiveness to your concerns
Physician's efforts to include you in descions regarding your treatment
Level of education you received regarding your condition
Amount of time the physician spent with you
Likelihood of your recommending this physician to others

* 6. Overall Assessment

  very poor poor fair good very good
Overall cheerfulness of our practice
Overall cleanliness of our practice
Overall rating of care during your visit
Likelihood of your recommending our practice to others

* 7. If you answered fair, poor, or very poor to any of the above questions, please explain why.

* 8. Comments/Suggestions

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