Michigan Head & Neck Institute - Patient Satisfaction Survey

Question Title

* 1. Was this your first experience with our office?

Yes

Question Title

* 2. About how long did you wait in the front reception area?

Less than 5 min.

5-15 min.

15-30 min.

Question Title

* 3. From your experience with our clinic, please rate the following:

	Excellent	Good	Average	Poor
Telephone Etiquette	Telephone Etiquette Excellent	Telephone Etiquette Good	Telephone Etiquette Average	Telephone Etiquette Poor
Parking Facilities	Parking Facilities Excellent	Parking Facilities Good	Parking Facilities Average	Parking Facilities Poor
Waiting Area	Waiting Area Excellent	Waiting Area Good	Waiting Area Average	Waiting Area Poor
Billing Procedures	Billing Procedures Excellent	Billing Procedures Good	Billing Procedures Average	Billing Procedures Poor
Scheduling	Scheduling Excellent	Scheduling Good	Scheduling Average	Scheduling Poor
Cleanliness of the Office	Cleanliness of the Office Excellent	Cleanliness of the Office Good	Cleanliness of the Office Average	Cleanliness of the Office Poor

Question Title

* 4. The receptionist...

greeted me pleasantly.

did not greet me pleasantly.

was competent.

was concerned.

was disrespectful.

was friendly.

was courteous.

was inefficient.

was informative.

The Receptionist's name was...

Question Title

* 5. The Technician/Assistant...

greeted me pleasantly.

did not greet me pleasantly.

was knowledgeable.

was concerned.

was competent.

was attentive.

was unfriendly.

was abrupt.

was informative.

The Technician's/Assistant's name was...

Question Title

* 6. Dr. Klein...

introduced himself professionally.

did not introduce himself professionally.

was knowledgeable.

was concerned.

was competent.

was attentive.

was unfriendly.

was abrupt.

was informative.

Other (please specify)

Question Title

* 7. How would you rate the overall services of our office?

	Excellent	Above Average	Average	Below Average	Poor
Rating	Rating Excellent	Rating Above Average	Rating Average	Rating Below Average	Rating Poor

Question Title

* 8. Would you recommend us to a friend or relative?

Yes

Question Title

* 9. Please add any comments or suggestions you might have to help us improve our business:

Question Title

* 10. Please leave us your contact information if you would like to, it is NOT required...if left blank, your answers will be anonymous.

Name:

Email Address:

Phone Number: