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* 1. Have you had surgery within the last 6 weeks?

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* 2. Please indicate the name of the doctor(s) you received treatment from at Newport Orthopedic Institute.

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* 3. At which Newport Orthopedic Institute location(s) did you receive care?

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* 4. Which of the following best describes your insurance status?

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* 5. On average, how long did you wait to see your provider?

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* 6. How satisfied were you with the following?

  Extremely Satisfied Very Satisfied Satisfied Very Dissatisfied Extremely Dissatisfied
A. Ease of making an appointment by phone
B. Getting an appointment in a reasonable amount of time
C. Location of your appointment
D. The efficiency of the check-in process
E. The friendliness, courtesy and sensitivity to your needs by our staff
F. Waiting time in the reception area
G. Waiting time in the exam room

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* 7. How would you rate the HealthiPass Kiosk Check-In System (iPad)?

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* 8. How Satisfied are you with the following?

  Extremely Satisfied Very Satisfied Satisfied Very Dissatisfied Extremely Dissatisfied
A. Ease of navigating our phone system?
B. The ease of which it took to reach a live person on the phone?
C. When you reached a live person, were they pleasant and helpful?
D. Ease to reach the correct person on the phone?
E. If you left a message, was your message returned with in 24 hours?

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* 9. How satisfied were you with your visits to the provider (Doctor, Physician Assistant or Nurse Practitioner)?

  Extremely Satisfied Very Satisfied Satisfied Very Dissatisfied Extremely Dissatisfied
A. Their willingness to listen carefully to you
B. Their explanation about your problem/condition
C. The amount of time your provider spent with you
D. Instructions you received about follow-up care
E. Empathized and understood what you are going through

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* 10. Did you receive a reminder Text, Email or Phone Call for your appointment and were you notified of the location?

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* 11. When leaving a message for your physician's surgery or procedure scheduler (i.e. injections), did you receive a response with 24-48 hours?

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* 12. How would you rate our staff's response time to your medical questions throughout your surgical or procedure experience (pre-surgery to post-surgery)?

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* 13. Did you feel prepared for your surgery? Please tell us why or why not below.

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* 14. Have you experienced billing issues since you've been a patient with Newport Orthopedic Institute? If yes, please indicate the issue(s) below in the space provided.

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* 15. How would you rate the Following:

  Clean and Organized Somewhat Clean A Little Disorganized Very Disorganized Completely Disorganized
Cleanliness of the Waiting Room
Appearance of the Reception Desk
Cleanliness of the Exam Room
Cleanliness of the Bathroom
Appearance of the Staff
Overall Appearance of the Office

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* 16. Would you recommend Newport Orthopedic Institute to your family or friends?

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* 17. What else can Newport Orthopedic Institute do to improve your overall patient experience?

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* 18. Name (optional) and contact information:

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