Patient Satisfaction Survey

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* 1. Please indicate which location you visited.

Elgin

Rockford

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* 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

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* 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

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* 4. Please select the most appropriate answer for each question.

	Poor	Unsatisfactory	Satisfactory	Good	Excellent	N/A
Physician's courtesy and willingness to answer questions	Physician's courtesy and willingness to answer questions Poor	Physician's courtesy and willingness to answer questions Unsatisfactory	Physician's courtesy and willingness to answer questions Satisfactory	Physician's courtesy and willingness to answer questions Good	Physician's courtesy and willingness to answer questions Excellent	Physician's courtesy and willingness to answer questions N/A
Your ability to reach our front office by phone	Your ability to reach our front office by phone Poor	Your ability to reach our front office by phone Unsatisfactory	Your ability to reach our front office by phone Satisfactory	Your ability to reach our front office by phone Good	Your ability to reach our front office by phone Excellent	Your ability to reach our front office by phone N/A
Length of waiting (from appointment time) in front reception area	Length of waiting (from appointment time) in front reception area Poor	Length of waiting (from appointment time) in front reception area Unsatisfactory	Length of waiting (from appointment time) in front reception area Satisfactory	Length of waiting (from appointment time) in front reception area Good	Length of waiting (from appointment time) in front reception area Excellent	Length of waiting (from appointment time) in front reception area N/A
Length of waiting time in the back clinical area	Length of waiting time in the back clinical area Poor	Length of waiting time in the back clinical area Unsatisfactory	Length of waiting time in the back clinical area Satisfactory	Length of waiting time in the back clinical area Good	Length of waiting time in the back clinical area Excellent	Length of waiting time in the back clinical area N/A
Courtesy and knowledge of our medical assistants	Courtesy and knowledge of our medical assistants Poor	Courtesy and knowledge of our medical assistants Unsatisfactory	Courtesy and knowledge of our medical assistants Satisfactory	Courtesy and knowledge of our medical assistants Good	Courtesy and knowledge of our medical assistants Excellent	Courtesy and knowledge of our medical assistants N/A
Courtesy and helpfulness regarding insurance/payments	Courtesy and helpfulness regarding insurance/payments Poor	Courtesy and helpfulness regarding insurance/payments Unsatisfactory	Courtesy and helpfulness regarding insurance/payments Satisfactory	Courtesy and helpfulness regarding insurance/payments Good	Courtesy and helpfulness regarding insurance/payments Excellent	Courtesy and helpfulness regarding insurance/payments N/A
Availability of desired time and location for appointment	Availability of desired time and location for appointment Poor	Availability of desired time and location for appointment Unsatisfactory	Availability of desired time and location for appointment Satisfactory	Availability of desired time and location for appointment Good	Availability of desired time and location for appointment Excellent	Availability of desired time and location for appointment N/A
Overall satisfaction with our practice	Overall satisfaction with our practice Poor	Overall satisfaction with our practice Unsatisfactory	Overall satisfaction with our practice Satisfactory	Overall satisfaction with our practice Good	Overall satisfaction with our practice Excellent	Overall satisfaction with our practice N/A
Overall satisfaction with your physician	Overall satisfaction with your physician Poor	Overall satisfaction with your physician Unsatisfactory	Overall satisfaction with your physician Satisfactory	Overall satisfaction with your physician Good	Overall satisfaction with your physician Excellent	Overall satisfaction with your physician N/A
Courtesy of our staff while checking in and out	Courtesy of our staff while checking in and out Poor	Courtesy of our staff while checking in and out Unsatisfactory	Courtesy of our staff while checking in and out Satisfactory	Courtesy of our staff while checking in and out Good	Courtesy of our staff while checking in and out Excellent	Courtesy of our staff while checking in and out N/A

Question Title

* 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

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* 6. Do you use our online patient portal to access your health and account information?

Yes

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* 7. How likely is it that you would recommend this company to a friend or colleague?

NOT AT ALL LIKELY

EXTREMELY LIKELY

Patient Satisfaction Survey

Question Title

* 1. Please indicate which location you visited.

Question Title

* 2. What was the key reason(s) you chose our practice for your eye care?

Question Title

* 3. How were you given registration paperwork prior to your visit?

Question Title

* 4. Please select the most appropriate answer for each question.

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* 5. Staff are treated fairly by the physician when mistakes are made.

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* 6. Do you use our online patient portal to access your health and account information?

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* 7. How likely is it that you would recommend this company to a friend or colleague?

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* 8. Do you have any other comments, questions, or concerns?