Visit Satisfaction Survey
1.
Overall, how satisfied or dissatisfied were you with your last visit to our office?
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
2.
Overall, how would you rate the service you received from the staff at our office?
Excellent
Very good
Good
Fair
Poor
3.
I was offered an appointment that was suitable for my schedule.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
4.
I feel I have adequate access to care with my provider.
Strongly agree
Agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Disagree
Strongly disagree
5.
Overall, how would you rate the care you received from your provider?
Excellent
Very good
Good
Fair
Poor
6.
How much do you trust your provider to make medical decisions that are in your best interests?
A great deal
A lot
A moderate amount
A little
Not at all
7.
My provider listened to my needs & answered my questions.
Strongly Agree
Agree
Somewhat agree or undecided
Disagree
Strongly Disagree
8.
My provider explained my treatment options & follow up care.
Strongly Agree
Agree
Somewhat agree or undecided
Disagree
Strongly disagree
9.
Overall, I am satisfied with the communication from my provider.
Strongly agree
Agree
Neither agree nor disagree
Disagree
Strongly disagree
10.
I would rate my satisfaction with the online patient portal as:
Excellent
Very good
Good
Fair
Poor
11.
I received a same day appointment with my complaint.
Not applicable (I was seen for a routine reason)
True
False
12.
Please share any other comments you have below: