PATIENT SATISFACTION SURVEY 2021 Question Title 1. Check below the name of your Primary Care Giver: Maria Cellario, MD Craig Metroka, MD Sajjad Mohammed, MD Dina Louie, PA Juan Bailey,MD Jerry Wolbert, FNP Marianne Clinton, MD Laura Crandall, MD Michelle Melchiorre, PA I do not receive primary care at Betances Question Title 2. Provider seen today: Dr. Thai Dina Louie Michelle Melchiorre Dr. Clinton Dr. Vincent Dr. Cellario Jerry Wolbert Dr. Bailey (Dentist) Yael Offer Jane Draimin Dr. Crandall Dr. Peng Dr. Mohammed Dr. Metroka Renata Shiloah Dr. Bailey (Primary Care) Other: Specify Question Title 3. How would you rate the ability to get a same day appointment when you request it? Excellent Good Fair Poor N/A Question Title 4. How would you rate the ability to get an appointment when you need one? Excellent Good Fair Poor Question Title 5. How would you rate the provider's office with sending you reminders between visits? Excellent Good Fair Poor Question Title 6. How would you rate calling the office, how helpful and courteous was the person who assisted you on the phone? Excellent Good Fair Poor Question Title 7. How would you rate the amount of time your provider spent with you? Excellent Good Fair Poor Question Title 8. How would you rate how well did the clinical team explain your care to you? Excellent Good Fair Poor Question Title 9. How would you rate the ability to understand and follow your provider's instruction regarding self-care, taking medications as prescribed, treatment plans and follow-up care you received from specialist Excellent Good Fair Poor Question Title 10. How would you rate our wait time? Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 20 minutes of your appointment time? Excellent Good Fair Poor Question Title 11. How would you rate how often anyone on the clinical team talk with you about specific goals for your health? Excellent Good Fair Poor Question Title 12. How would you rate how often anyone on the clinical team ask you if there are things that make it hard for you to take care of your health? Excellent Good Fair Poor Question Title 13. How would you rate the hours of operation of the clinic? Excellent Good Fair Poor Question Title 14. Overall, how would you rate your experience with us? Excellent Good Fair Poor Question Title 15. How would you rate how likely are you to recommend our practice to a friend or love one? Excellent Good Fair Poor Question Title 16. Please write any comments, questions, or concerns you have regarding your service experience. Question Title 17. Patient Language English Spanish Chinese Question Title 18. Date Date / Time Date Next