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Patient Satisfaction Survey v05E
*
1.
Are you a
new patient
at BCOM?
(Required.)
Yes
No
*
2.
Where
did you access care today?
(Required.)
Hollywood
Lauderhill
Pompano Beach
Dental
- Pompano Beach
West Park
via Telehealth
*
3.
How easy was it to
schedule
your appointment?
(Required.)
Very Easy
Easy
Hard
Very Hard
Very Easy
Easy
Hard
Very Hard
*
4.
Who was the
provider
that saw you today?
(Required.)
Dr. Chery
Dr. Barros
Dr. Hossain
Dr. Germain-George
Dr. Gotrace
Dr. Williams
Ms. Adesca
Ms. Almaral
Ms. Hall
Ms. James-Sylvain
Ms. Mekic-Ruiz
Ms. Maxton
Ms. Hernandez Delas
Mr. Georges
Mr. Jouissance
Ms. Yu
Ms. Appel (Dietitian)
Ms. Hines (LCSW)
Ms. Moncada Aranda (LCSW)
Ms. Delgado (LCSW)
Dr. Deligent (Behavioral Health)
Ms. Joseph (Behavioral Health)
Dr. Salas (Dentist)
Dr. Trenkova (Dentist)
Mr. Cruz Gonzalvez (Dental Hygienist)
Other (please specify)
*
5.
How would you rate the
overall care
you received from your provider?
(Required.)
Very Good
Good
Poor
Very Poor
Very Good
Good
Poor
Very Poor
*
6.
How well do you
understand the information
you received regarding the your care/treatment plan (
i.e., medications, ongoing care & goals, follow-up, and/or referrals
):
(Required.)
Very Well
Well
Somewhat
Not at All
Very Well
Well
Somewhat
Not at All
*
7.
How likely are you to
recommend
BCOM to family or friends?
(Required.)
Very Likely
Likely
Unlikely
Very Unlikely
Very Likely
Likely
Unlikely
Very Unlikely
8.
Is there any staff member who you would like to recognize for providing
exceptional service
during today's visit? (
Optional
)
9.
How might we improve your
overall experience
at our health center? List any comments or concerns.
(Optional)
*
10.
What is your age range?
(Required.)
20 and below
21 to 30
31 to 40
41 to 50
51 to 60
61 to 70
71+
*
11.
We value your feedback and may need to follow up to learn more about your experience. Would you be open to a member of our team reaching out if needed?
(Required.)
Yes
No
Current Progress,
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