* 1. Date of Visit

* 5. If you answered yes to the previous question, please rate your experience.

* 6. Please rate the following according to scale

  Poor Fair Good Very Good Excellent N/A
The length of time it took to get an appointment:
The manner in which you were treated by the front desk and/or clinic staff:
How attentive was the staff to your needs?
The manner in which you were treated by your physician:
The thoroughness of your medical evaluation:
The amount of time spent with your physician:
How well your medical concerns and/or questions were addressed by your physician:
How likely would you be to recommend the care you received at this physician practice to a friend or family member?
Ease of surgery scheduling(if applicable):
Ease of communication with office or staff by phone:
The amount of wait time in the reception area:
Please give an overall evaluation of the care you received:

* 7. Are there any improvements you would like to see made to our office for any future visits?

* 8. General Feedback