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Patient Satisfaction Survey
1.
Please indicate which location you visited.
Elgin
Rockford
2.
What was the key reason(s) you chose our practice for your eye care?
Specific Eye Doctor
Primary Care Doctor Referral
Specialist Referral
Hospital Referral
Family or Friend Referral
Insurance
Internet Ad / Website
3.
How were you given registration paperwork prior to your visit?
Given at referring providers office
Received in mail
Given upon arrival
Printed from Website
4.
Please select the most appropriate answer for each question.
Poor
Unsatisfactory
Satisfactory
Good
Excellent
N/A
Length of waiting time in the back clinical area
Availability of desired time and location for appointment
Physician's courtesy and willingness to answer questions
Length of waiting (from appointment time) in front reception area
Courtesy of our staff while checking in and out
Your ability to reach our front office by phone
Courtesy and knowledge of our medical assistants
Courtesy and helpfulness regarding insurance/payments
Overall satisfaction with our practice
Overall satisfaction with your physician
5.
Staff are treated fairly by the physician when mistakes are made.
Strongly Disagree
Disagree
Neither Agree nor Disagree
Agree
Strongly Agree
Does Not Apply or Don't Know
6.
Do you use our online patient portal to access your health and account information?
Yes
No
7.
On a scale of 0 to 10,
How likely is it that you would recommend this company to a friend or colleague?
0 for Not at all likely, 10 for Extremely likely
Not at all likely
Extremely likely
0
1
2
3
4
5
6
7
8
9
10
8.
Do you have any other comments, questions, or concerns?
Current Progress,
0 of 8 answered