Patient Experience Survey
*
1.
How was the appointment for your visit scheduled?
(Required.)
in person
I called the office
The office called me
Please rate each by circling the number that
best describes your opinion
*
2.
How would you rate the length of time it took between making your appointment and the visit.
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not Applicable/
No Opinion
Poor
Fair
Good
Very Good
Excellent
Not Applicable/
No Opinion
*
3.
How would you rate the helpfullness of the reception staff? (before and upon arrival for your exam)
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not Applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not Applicable/
No opinion
*
4.
How would you rate the hours we are open?
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
*
5.
How would you rate the willingness of our staff to answer any of your questions?
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
*
6.
How would you rate the time and care the technologist took to explain your exam to you?
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Technologist Name/Exam Performed:
*
7.
Please rate your comfort level during your exam. (courtesy and respect you were given, friendliness and kindness)
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
*
8.
Please rate the thoroughness of the technologist to explain the end of your exam. (proceed to change and exit; book another appt before leaving; timeliness of reporting)
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
*
9.
Please rate the cleanliness and neatness of our clinic.
(Required.)
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
Poor
Fair
Good
Very Good
Excellent
Not applicable/
No opinion
*
10.
Would you recommend the clinic to a friend or family member?
(Required.)
Yes
No
11.
Regarding your overall experience visiting our clinic, please list things that we are doing well.
12.
If there were some things you could change about this visit to improve it, what would they be?