Customer Satisfaction Survey 2 Question Title * 1. YOUR APPOINTMENT Excellent Very Good Good Fair Poor N/A Ease of making appointments by phone Ease of making appointments by phone Excellent Ease of making appointments by phone Very Good Ease of making appointments by phone Good Ease of making appointments by phone Fair Ease of making appointments by phone Poor Ease of making appointments by phone N/A Appointment available within a reasonable amount of time Appointment available within a reasonable amount of time Excellent Appointment available within a reasonable amount of time Very Good Appointment available within a reasonable amount of time Good Appointment available within a reasonable amount of time Fair Appointment available within a reasonable amount of time Poor Appointment available within a reasonable amount of time N/A Getting care for illness/injury as soon as you wanted it Getting care for illness/injury as soon as you wanted it Excellent Getting care for illness/injury as soon as you wanted it Very Good Getting care for illness/injury as soon as you wanted it Good Getting care for illness/injury as soon as you wanted it Fair Getting care for illness/injury as soon as you wanted it Poor Getting care for illness/injury as soon as you wanted it N/A Getting after-hours care when you needed it Getting after-hours care when you needed it Excellent Getting after-hours care when you needed it Very Good Getting after-hours care when you needed it Good Getting after-hours care when you needed it Fair Getting after-hours care when you needed it Poor Getting after-hours care when you needed it N/A Ease of getting a referral when you needed one Ease of getting a referral when you needed one Excellent Ease of getting a referral when you needed one Very Good Ease of getting a referral when you needed one Good Ease of getting a referral when you needed one Fair Ease of getting a referral when you needed one Poor Ease of getting a referral when you needed one N/A Question Title * 2. OUR STAFF: Excellent Very Good Good Fair Poor N/A The courtesy of the person who took your call The courtesy of the person who took your call Excellent The courtesy of the person who took your call Very Good The courtesy of the person who took your call Good The courtesy of the person who took your call Fair The courtesy of the person who took your call Poor The courtesy of the person who took your call N/A The friendliness and courtesy of the receptionist The friendliness and courtesy of the receptionist Excellent The friendliness and courtesy of the receptionist Very Good The friendliness and courtesy of the receptionist Good The friendliness and courtesy of the receptionist Fair The friendliness and courtesy of the receptionist Poor The friendliness and courtesy of the receptionist N/A The caring concern of our nurses/medical assistants The caring concern of our nurses/medical assistants Excellent The caring concern of our nurses/medical assistants Very Good The caring concern of our nurses/medical assistants Good The caring concern of our nurses/medical assistants Fair The caring concern of our nurses/medical assistants Poor The caring concern of our nurses/medical assistants N/A The helpfulness of the people who assisted you with billing or insurance The helpfulness of the people who assisted you with billing or insurance Excellent The helpfulness of the people who assisted you with billing or insurance Very Good The helpfulness of the people who assisted you with billing or insurance Good The helpfulness of the people who assisted you with billing or insurance Fair The helpfulness of the people who assisted you with billing or insurance Poor The helpfulness of the people who assisted you with billing or insurance N/A Question Title * 3. OUR COMMUNICATION WITH YOU: Excellent Very Good Good Fair Poor N/A Your phone calls answered promptly Your phone calls answered promptly Excellent Your phone calls answered promptly Very Good Your phone calls answered promptly Good Your phone calls answered promptly Fair Your phone calls answered promptly Poor Your phone calls answered promptly N/A Getting advice or help when needed during office hours Getting advice or help when needed during office hours Excellent Getting advice or help when needed during office hours Very Good Getting advice or help when needed during office hours Good Getting advice or help when needed during office hours Fair Getting advice or help when needed during office hours Poor Getting advice or help when needed during office hours N/A Your test results reported in a reasonable amount of time Your test results reported in a reasonable amount of time Excellent Your test results reported in a reasonable amount of time Very Good Your test results reported in a reasonable amount of time Good Your test results reported in a reasonable amount of time Fair Your test results reported in a reasonable amount of time Poor Your test results reported in a reasonable amount of time N/A Our ability to return calls in a timely manner Our ability to return calls in a timely manner Excellent Our ability to return calls in a timely manner Very Good Our ability to return calls in a timely manner Good Our ability to return calls in a timely manner Fair Our ability to return calls in a timely manner Poor Our ability to return calls in a timely manner N/A Your ability to obtain prescription refills by phone Your ability to obtain prescription refills by phone Excellent Your ability to obtain prescription refills by phone Very Good Your ability to obtain prescription refills by phone Good Your ability to obtain prescription refills by phone Fair Your ability to obtain prescription refills by phone Poor Your ability to obtain prescription refills by phone N/A Question Title * 4. YOUR VISIT WITH THE PROVIDER:(Doctor, Physician Assistant, Nurse Practitioner) Excellent Very Good Good Fair Poor N/A Willingness to listen carefully to you Willingness to listen carefully to you Excellent Willingness to listen carefully to you Very Good Willingness to listen carefully to you Good Willingness to listen carefully to you Fair Willingness to listen carefully to you Poor Willingness to listen carefully to you N/A Taking time to answer your questions Taking time to answer your questions Excellent Taking time to answer your questions Very Good Taking time to answer your questions Good Taking time to answer your questions Fair Taking time to answer your questions Poor Taking time to answer your questions N/A Explaining things in a way you could understand Explaining things in a way you could understand Excellent Explaining things in a way you could understand Very Good Explaining things in a way you could understand Good Explaining things in a way you could understand Fair Explaining things in a way you could understand Poor Explaining things in a way you could understand N/A Instructions regarding medication/follow-up care Instructions regarding medication/follow-up care Excellent Instructions regarding medication/follow-up care Very Good Instructions regarding medication/follow-up care Good Instructions regarding medication/follow-up care Fair Instructions regarding medication/follow-up care Poor Instructions regarding medication/follow-up care N/A Advice given to you on ways to stay healthy Advice given to you on ways to stay healthy Excellent Advice given to you on ways to stay healthy Very Good Advice given to you on ways to stay healthy Good Advice given to you on ways to stay healthy Fair Advice given to you on ways to stay healthy Poor Advice given to you on ways to stay healthy N/A Question Title * 5. Patient Portal:Have you accessed your Patient Portal within the past 6 months? Yes No Question Title * 6. If yes, for what reason: (check all that apply) Sent a message to my provider Reviewed my visit note Requested a medication refill Downloaded Educational Materials Reviewed Lab Results Question Title * 7. OUR FACILITY Excellent Very Good Good Fair Poor N/A Hours of operation convenient for you Hours of operation convenient for you Excellent Hours of operation convenient for you Very Good Hours of operation convenient for you Good Hours of operation convenient for you Fair Hours of operation convenient for you Poor Hours of operation convenient for you N/A Overall comfort Overall comfort Excellent Overall comfort Very Good Overall comfort Good Overall comfort Fair Overall comfort Poor Overall comfort N/A Adequate parking Adequate parking Excellent Adequate parking Very Good Adequate parking Good Adequate parking Fair Adequate parking Poor Adequate parking N/A Signage and directions easy to follow Signage and directions easy to follow Excellent Signage and directions easy to follow Very Good Signage and directions easy to follow Good Signage and directions easy to follow Fair Signage and directions easy to follow Poor Signage and directions easy to follow N/A Question Title * 8. YOUR OVERALL SATISFACTION WITH Excellent Very Good Good Fair Poor N/A Our practice Our practice Excellent Our practice Very Good Our practice Good Our practice Fair Our practice Poor Our practice N/A The quality of your medical care The quality of your medical care Excellent The quality of your medical care Very Good The quality of your medical care Good The quality of your medical care Fair The quality of your medical care Poor The quality of your medical care N/A Overall rating of care from your provider or nurse Overall rating of care from your provider or nurse Excellent Overall rating of care from your provider or nurse Very Good Overall rating of care from your provider or nurse Good Overall rating of care from your provider or nurse Fair Overall rating of care from your provider or nurse Poor Overall rating of care from your provider or nurse N/A Question Title * 9. Would you recommend the provider to others? YES NO If no, please tell us why Question Title * 10. Name of Practitioner that treated you Question Title * 11. Facility you visited Question Title * 12. Reason for visit Sick Well Visit/Physical Other Question Title * 13. IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT Question Title * 14. SOME INFORMATION ABOUT YOU Under 18 18-30 31-40 41-50 51-60 Over 60 Male Male Under 18 Male 18-30 Male 31-40 Male 41-50 Male 51-60 Male Over 60 Female Female Under 18 Female 18-30 Female 31-40 Female 41-50 Female 51-60 Female Over 60 Question Title * 15. Are you a New Patient Existing Patient Next
