Hattiesburg Clinic Patient Survey Online

At Hattiesburg Clinic, we want to ensure that we provide you an excellent patient experience. Please take a moment and tell us how we're doing.

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* 1. My comments are based on my recent visit with:

Name of physician or other staff member:

Location or Department:

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* 2. Please rate the following:

	Poor	Fair	Good	Very Good	Excellent	N/A
Courtesy, sensitivity and friendliness of the staff on the telephone	Courtesy, sensitivity and friendliness of the staff on the telephone Poor	Courtesy, sensitivity and friendliness of the staff on the telephone Fair	Courtesy, sensitivity and friendliness of the staff on the telephone Good	Courtesy, sensitivity and friendliness of the staff on the telephone Very Good	Courtesy, sensitivity and friendliness of the staff on the telephone Excellent	Courtesy, sensitivity and friendliness of the staff on the telephone N/A
Length of time waiting at the office	Length of time waiting at the office Poor	Length of time waiting at the office Fair	Length of time waiting at the office Good	Length of time waiting at the office Very Good	Length of time waiting at the office Excellent	Length of time waiting at the office N/A
Time spent with the physician/health care provider	Time spent with the physician/health care provider Poor	Time spent with the physician/health care provider Fair	Time spent with the physician/health care provider Good	Time spent with the physician/health care provider Very Good	Time spent with the physician/health care provider Excellent	Time spent with the physician/health care provider N/A
Explanation of what was done for you	Explanation of what was done for you Poor	Explanation of what was done for you Fair	Explanation of what was done for you Good	Explanation of what was done for you Very Good	Explanation of what was done for you Excellent	Explanation of what was done for you N/A
Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw	Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw Poor	Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw Fair	Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw Good	Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw Very Good	Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw Excellent	Technical skills (thoroughness, carefulness, competence) of the physician or health care provider that you saw N/A
Courtesy, sensitivity and friendliness of physician or health care provider	Courtesy, sensitivity and friendliness of physician or health care provider Poor	Courtesy, sensitivity and friendliness of physician or health care provider Fair	Courtesy, sensitivity and friendliness of physician or health care provider Good	Courtesy, sensitivity and friendliness of physician or health care provider Very Good	Courtesy, sensitivity and friendliness of physician or health care provider Excellent	Courtesy, sensitivity and friendliness of physician or health care provider N/A
Courtesy, sensitivity and friendliness of nursing staff	Courtesy, sensitivity and friendliness of nursing staff Poor	Courtesy, sensitivity and friendliness of nursing staff Fair	Courtesy, sensitivity and friendliness of nursing staff Good	Courtesy, sensitivity and friendliness of nursing staff Very Good	Courtesy, sensitivity and friendliness of nursing staff Excellent	Courtesy, sensitivity and friendliness of nursing staff N/A
Courtesy, sensitivity and friendliness of reception staff	Courtesy, sensitivity and friendliness of reception staff Poor	Courtesy, sensitivity and friendliness of reception staff Fair	Courtesy, sensitivity and friendliness of reception staff Good	Courtesy, sensitivity and friendliness of reception staff Very Good	Courtesy, sensitivity and friendliness of reception staff Excellent	Courtesy, sensitivity and friendliness of reception staff N/A
Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic	Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic Poor	Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic Fair	Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic Good	Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic Very Good	Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic Excellent	Overall, how would you rate the service you received at your last visit with Hattiesburg Clinic N/A

If your answer is fair or poor to any of the above questions, please tell us why:

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* 3. I am:

a new patient to this department at Hattiesburg Clinic

an existing patient to this department at Hattiesburg Clinic

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* 4. How did you hear about us?

Magazine

Billboard

Physician referral

Friend/family member

Phone directory

Radio

Newspaper

Internet

Other

If other please specify:

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* 5. Would you refer your family/friends to Hattiesburg Clinic?

Yes

If no, please tell us why:

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* 6. Please share your suggestions to help us improve our service to you.

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* 7. From time to time, Hattiesburg Clinic may decide to hold confidential Patient Focus Groups to help us better serve you. Would you be willing to participate? (If yes, please provide personal information below so that we can contact you at a later date with more information if we hold a focus group.)

Yes

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* 8. Personal Information (optional)

Name:

Email Address:

Phone Number: